2 Dec 2016 Joshua Harry Smith · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 3
Failure to recognise location information from 999 calls View source Failure to identify location from mobile 999 calls View source Failure to immediately alert police and other emergency services from 999 call information View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Maritime and Coastguard Agency North East Ambulance Service NHS Foundation Trust Northumberland Fire and Rescue Service Northumbria Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
North East Ambulance Service NHS Foundation Trust and Northumbria Police
Consider sourcing Mountain Rescue expertise and using SARLOC to improve location identification in relevant incidents.
View source
Northumberland Fire and Rescue Service
Dual-monitor emergency calls and immediately review confirmed or suspected missing-person calls independently of the call handler.
View source
Northumberland Fire and Rescue Service
Confirm Fire Control procedures for mobilising to EISEC locations that include sea or water areas.
View source
Maritime and Coastguard Agency
Issue updated operational guidance addressing the identified emergency communications limitation.
View source
Maritime and Coastguard Agency
Modify training packages to reflect the updated operational guidance.
View source
North East Ambulance Service NHS Foundation Trust and Northumbria Police
Deliver THRIVE training to NEAS call handlers to improve identification of triggers requiring other emergency services.
View source
North East Ambulance Service NHS Foundation Trust and Northumbria Police
Provide Tactical Advisors to support faster tactical responses and improve inter-agency communication.
View source
North East Ambulance Service NHS Foundation Trust and Northumbria Police
Finalise, approve and use the revised procedure for responding to 999 calls concerning water-based incidents.
View source See 5 more actions
×
AI-generated summary
Joshua Harry Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise location information from 999 calls
Wider context from the report “The search for Joshua continued at Berwick Holiday Park (on the north side of the River Tweed and the town of Berwick-upon-Tweed) as a result of his location at Spittal Beach not being recognised from his 999 call .
After Joshua’s phone call was ‘listened back’ it was observed that he had described his location as Spittal, at the bottom of a cliff, near Spittal beach.
” Source location Joshua Harry Smith · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify location from mobile 999 calls
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” Source location Joshua Harry Smith · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to immediately alert police and other emergency services from 999 call information
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” Source location Joshua Harry Smith · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider sourcing Mountain Rescue expertise and using SARLOC to improve location identification in relevant incidents.
Verbatim wording from the response “Your report identifies the fact that Joshua’s location could not be clearly identified using his mobile phone. As you are aware, the topography of the area (on or near cliffs) made triangulation difficult. Northumberland National Park Mountain Rescue have advised other agencies of a further software tool available to them, SARLOC, which enables a text message to be sent to a missing person’s phone. If the phone is a smartphone, the missing person is then able to click on the message and, using the internet, the smartphone provides Mountain Rescue with the location. Although this system cannot be independently utilised by other agencies, Mountain Rescue teams are able to distribute a notification of the casualty’s whereabouts to all partner agencies upon notification of an incident to them.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dual-monitor emergency calls and immediately review confirmed or suspected missing-person calls independently of the call handler.
Verbatim wording from the response “Although the call handling and initial mobilising for the incident were not undertaken by NFRS Fire Control personnel, steps have been taken to confirm, and reaffirm, the procedures which would be applied within our Fire Control in the event of NFRS receiving a similar 999 call. Our policy for any emergency call to be 'dual monitored' as it is being taken by a duty supervisory manager to reduce the risk of a mobilisation error, incorrect information being relayed to responding crews or an incorrect address being recorded. As an additional confidence and assurance measure, NFRS have adopted a policy of instigating an immediate review of the call by someone other than the call handler whenever a call has been placed by a confirmed or suspected, missing person.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Confirm Fire Control procedures for mobilising to EISEC locations that include sea or water areas.
Verbatim wording from the response “NFRS have also reviewed the control procedure when using Enhanced Information Service Emergency Calls (EISEC) which allows Fire Control to pinpoint mobile phone signals within a specific area. We have confirmed that Fire Control would follow normal procedure and mobilise to this area even if the target zone covered part of the sea or water area.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue updated operational guidance addressing the identified emergency communications limitation.
Verbatim wording from the response “Regarding the matters of concern, Her Majesty’s Coastguard (HMCG) has noted the North East Ambulance Communications system limitation surrounding the inability to ‘play back’ live 999 calls. We have also reviewed our own systems, and updated guidance has been issued and training packages modified.” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify training packages to reflect the updated operational guidance.
Verbatim wording from the response “Regarding the matters of concern, Her Majesty’s Coastguard (HMCG) has noted the North East Ambulance Communications system limitation surrounding the inability to ‘play back’ live 999 calls. We have also reviewed our own systems, and updated guidance has been issued and training packages modified.” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver THRIVE training to NEAS call handlers to improve identification of triggers requiring other emergency services.
Verbatim wording from the response “With the above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways licence requirements and maintain focus on the clinical complaint. However, in order to enhance the skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers that would alert them to the need for other emergency services, as a result of joint work with Police colleagues, a specific THRIVE training program for NEAS has been devised with commencement of delivery in March 2017. This further training will ensure that there is, so far as possible, a consistency of response between Control Room staff across agencies. Furthermore, NEAS operational staff have received training in NDM and Joint Emergency Services Interoperability Programme (JESIP) principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Tactical Advisors to support faster tactical responses and improve inter-agency communication.
Verbatim wording from the response “As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised in your Report), and a decision regarding the appropriation of this response is made more quickly and (2) communication between agencies is improved. This very point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated “Control action following 999 calls to water incidents” procedure in use at NEAS. The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise, approve and use the revised procedure for responding to 999 calls concerning water-based incidents.
Verbatim wording from the response “As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised in your Report), and a decision regarding the appropriation of this response is made more quickly and (2) communication between agencies is improved. This very point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated “Control action following 999 calls to water incidents” procedure in use at NEAS. The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NEAS cannot remove closed questioning because Call Handlers must comply with NHS Pathways licence requirements and maintain clinical focus.
Verbatim wording from the response “A number of questions asked by the Call Handler were of the “closed” type, which limited the opportunity for Joshua to be more specific about his location. The nature of the questions posed by the Call Handler may be explained by the fact the NHS Pathways telephone triage system in use by the North East Ambulance Service requires Call Handlers to ask closed questions in order to identify the nature of the medical complaint and provide the most accurate ambulance response. Failure to follow NHS Pathways may lead to increased clinical risk and, ultimately, potentially unsafe calls.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
17 Nov 2016 Brian Mills · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1
Failure to manage outstanding emergency calls and waiting times within target response times View source
Linked response
East of England Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
East of England Ambulance Service NHS Trust
Increase clinician staffing in Emergency Operations Centres to treat more patients by telephone and refer them to appropriate pathways.
View source
East of England Ambulance Service NHS Trust
Release ambulance crews from hospital emergency-department queues to attend patients with life-threatening community conditions.
View source
East of England Ambulance Service NHS Trust
Negotiate with regulators and commissioners regarding funding needed to address the Trust’s capacity gap.
View source
East of England Ambulance Service NHS Trust
Recruit hundreds of patient-facing staff within the available financial envelope.
View source See 1 more action
×
AI-generated summary
Brian Mills · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Mills, an 88-year-old man on warfarin, fell at home and sustained multiple injuries, including broken ribs and a bleeding head wound. An ambulance was called, but a rapid response vehicle arrived over two hours later and an ambulance arrived subsequently; he died on 13 April 2016. The principal concern was that consistently high levels of outstanding emergency calls and excessive waiting times could put lives at risk. Evidence heard at the inquest stated that the ambulance delay did not, in this case, cause or contribute to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to manage outstanding emergency calls and waiting times within target response times
Wider context from the report “(1) Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.
” Source location Brian Mills · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase clinician staffing in Emergency Operations Centres to treat more patients by telephone and refer them to appropriate pathways.
Verbatim wording from the response “These are not response times that we would want or expect but are part of the increasing pressure on our system. A number of mitigating initiatives have been introduced led by the Trust Medical Director to protect patient safety during these periods of pressure when responses to Green patients are delayed. These include increasing the number of clinicians in the Emergency Operations Centres (EOC) to increase the number of patients treated over the phone and referred to appropriate pathways. Following consultation with hospital colleagues we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Release ambulance crews from hospital emergency-department queues to attend patients with life-threatening community conditions.
Verbatim wording from the response “These are not response times that we would want or expect but are part of the increasing pressure on our system. A number of mitigating initiatives have been introduced led by the Trust Medical Director to protect patient safety during these periods of pressure when responses to Green patients are delayed. These include increasing the number of clinicians in the Emergency Operations Centres (EOC) to increase the number of patients treated over the phone and referred to appropriate pathways. Following consultation with hospital colleagues we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Negotiate with regulators and commissioners regarding funding needed to address the Trust’s capacity gap.
Verbatim wording from the response “In line with the Trust's strategic objective to improve service delivery to our patients, we are negotiating with regulators and commissioners on the funding required to meet the acknowledged capacity gap at EEAST. We continue to recruit hundreds of patient facing staff within the financial envelope provided which in the environment of increasing activity is the only sustainable solution to delayed responses to patients.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit hundreds of patient-facing staff within the available financial envelope.
Verbatim wording from the response “In line with the Trust's strategic objective to improve service delivery to our patients, we are negotiating with regulators and commissioners on the funding required to meet the acknowledged capacity gap at EEAST. We continue to recruit hundreds of patient facing staff within the financial envelope provided which in the environment of increasing activity is the only sustainable solution to delayed responses to patients.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust lacks capacity to deliver national NHS response-time targets amid rising demand and an acknowledged capacity gap.
Verbatim wording from the response “In the context of ever growing demand, we also need to be clear that while we are taking every possible step we can, we do not have the capacity available to deliver national NHS Response Times Targets.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
19 Jul 2016 Patricia Mercieca · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3
Failure to contact the manager for emergency callers where a manager is available View source Failure to obtain further information or reassess when directed by emergency services or relevant professionals View source Failure to pass requested further information back to the requesting agency or professional View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Patricia Mercieca · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Mercieca, who had severe COPD and asthma and lived in assisted accommodation, pulled her emergency cord on 14 July 2015 and said that she could not breathe. She arrested shortly afterwards and was found deceased when the ambulance service arrived. Concerns included failures to provide correct information and follow up when she did not respond, to contact the resident manager, and to pass on relevant medical history and information requested by emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to contact the manager for emergency callers where a manager is available
Wider context from the report “(2) That wherever there is a person contacting them in an emergency where there is a manager, that manager should be contacted whatever authority covers the person contacting the call handler.
” Source location Patricia Mercieca · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain further information or reassess when directed by emergency services or relevant professionals
Wider context from the report “(3) That if a call handler is directed by emergency services such as the LAS, or other relevant professionals such as a doctor to obtain further information or reassess then they should do so and pass any information so gained back to the agency or professional that requested it.
” Source location Patricia Mercieca · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to pass requested further information back to the requesting agency or professional
Wider context from the report “(3) That if a call handler is directed by emergency services such as the LAS, or other relevant professionals such as a doctor to obtain further information or reassess then they should do so and pass any information so gained back to the agency or professional that requested it .
” Source location Patricia Mercieca · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to appropriately triage and manage emergency calls View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
William Robert Raymond Nute · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to appropriately triage and manage emergency calls
Wider context from the report “That the 999 calls from the public were not triaged by the call handlers at BT or South Western Ambulance appropriately and managed .
” Source location William Robert Raymond Nute · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate as a trial site in the Ambulance Response Programme’s new call-coding system.
Verbatim wording from the response “ARP has now developed a new call coding set which has been trialling in two sites - South Western Ambulance Service NHS Foundation Trust and Yorkshire Ambulance Service for a minimum of 12 weeks since April 2016.” Source location 2016-0229-Response-by-South-Western-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The original emergency call was triaged correctly, achieving 97% compliance against the applicable 86% pass rate.
Verbatim wording from the response “In terms of the question as to whether the call received was triaged appropriately, I can confirm that ████████ investigation confirmed that the disposition reached for the original call was indeed correct. An audit of this call was undertaken as part of the investigation, which confirmed the call achieved 97% compliance against a pass rate of 86%. That said, it is acknowledged that the police were not notified of the incident until 12.56, an hour after the original call had been received. I am aware that concerns were raised during the inquest that the delay in notifying the police could have led to the driver of the vehicle leaving the scene and furthermore, placed a responsibility on those members of public on scene to effectively shield Mr Nute from passing traffic.” Source location 2016-0229-Response-by-South-Western-Ambulance-Service-NHS-Trust
Open published response
19 May 2016 Samuel Rodney Darren BLAIR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Delay in providing the ambulance with the prison gate location View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
London Ambulance Service NHS Trust Pentonville Prison
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Pentonville Prison
Require prison control rooms to provide the gate location at the beginning of ambulance calls and brief staff on the requirement.
View source
London Ambulance Service NHS Trust
Update the Computerised Gazetteer with both HMP Pentonville vehicular entrances and their postal addresses.
View source
London Ambulance Service NHS Trust
Request HMP Pentonville staff to state the required ambulance entrance at the beginning of every 999 call.
View source
London Ambulance Service NHS Trust
Deliver refresher training requiring emergency medical dispatchers to confirm the HMP Pentonville entrance at the start of each call.
View source See 1 more action
×
AI-generated summary
Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delay in providing the ambulance with the prison gate location
Wider context from the report “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.
The LAS controller did not ask at the very outset.
The ideal would be for the information to be given at the very beginning of any emergency call .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)
” Source location Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require prison control rooms to provide the gate location at the beginning of ambulance calls and brief staff on the requirement.
Verbatim wording from the response “The separate report addressed to the Governor raises concern about the fact that the prison’s control room did not immediately provide the London Ambulance Service (LAS) with the gate location when they requested the attendance of an ambulance. I can confirm that since Mr Blair’s death, colleagues at Pentonville have met the LAS to discuss this issue, and it has been agreed that the prison gate location will be” Source location 2016-0196-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Computerised Gazetteer with both HMP Pentonville vehicular entrances and their postal addresses.
Verbatim wording from the response “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request HMP Pentonville staff to state the required ambulance entrance at the beginning of every 999 call.
Verbatim wording from the response “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher training requiring emergency medical dispatchers to confirm the HMP Pentonville entrance at the start of each call.
Verbatim wording from the response “I have been assured by ████████, the LAS’s Deputy Director of Operations (Control Services), ████████ that in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
18 May 2016 Christopher Philip Fields · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Christopher Philip Fields · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
Wider context from the report “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response , suggests that the algorithms used for coding are not accurate and not fit for purpose . In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied . (NWAS, SECRETARY OF STATE and NHS ENGLAND)
” Source location Christopher Philip Fields · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.
Verbatim wording from the response “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the” Source location 2016-0194-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial a new ambulance coding system.
Verbatim wording from the response “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the” Source location 2016-0194-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.
Verbatim wording from the response “In regards to AMPDS system, I confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s chest had been ‘concealed in’ this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response. I note that the attending police officers evidence supported that the patient was breathing, conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patient’s condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment). Furthermore this assertion was reinforced by ████████ Pathologist report which supported that the critical injury was sustained during the second assault.” Source location 2016-0194-Response-by-North-West-Ambulance-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.
Verbatim wording from the response “I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.” Source location 2016-0194-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.
Verbatim wording from the response “However, please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concerns about the design of the product you may wish to contact them direct at the following address:” Source location 2016-0194-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.
Verbatim wording from the response “I note the response from North West Ambulance Service (NWAS), letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time. It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist’s report.” Source location 2016-0194-Response-by-NHS-England
Open published response
15 Apr 2016 Luke Christie AYRES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure of ward staff to call 999 directly View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Luke Christie AYRES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Christie AYRES, aged 24, died on 27 September 2015 while serving a custodial sentence as an inpatient at Raeside Clinic. He was found hanging by a ligature in his bedroom and could not be resuscitated. Concerns included delays and communication risks in contacting the ambulance service, and the absence of staff to escort paramedics from reception to the ward.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ward staff to call 999 directly
Wider context from the report “1. The 999 call to the ambulance service made by Raeside reception after the issuing of a 2222 medical emergency call was cut off when they attempted to transfer the Ambulance Service to Ward Severn. The ambulance Service therefore had to get the number from the operator and called back a minute later. When they were put through to the Ward the person they were speaking with was not at Luke’s side and did not know his current status because she was in an office some distance away from him and the staff with him. There is no evidence that this actually had an impact on Luke’s death but there are risks for the future arising from the fact that:
a) the Ward staff do not call 999 themselves necessitating a delay and a risk of the call being cut off when the call is transferred to the Ward ; and
b) the person providing information to the Ambulance Service may not know the patient’s current status and could therefore give incorrect information.
” Source location Luke Christie AYRES · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace Reaside Clinic’s telephony system with the Trust’s standard system.
Verbatim wording from the response “During the inquest, evidence gave rise to concern about the procedures associated with the handling of medical emergency calls at Reaside Clinic, together with a lack of assurance that Paramedics would always be greeted in reception by a member of ward staff who could immediately escort them to the scene of the incident.” Source location 2016-0148-Response-by-Birmingham-and-Solihull-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.
Verbatim wording from the response “We have therefore decided to extend the simulation of medical emergencies on our wards at Reaside to include the connection of the call to the ambulance service and to also ensure that the individual nominated to make the call has all of the relevant medical information and observations of the patient to hand. We currently deliver quarterly medical emergency simulation exercises at Reaside Clinic (the most recent being just 2 weeks ago) and will explore the possibility of increasing the frequency.” Source location 2016-0148-Response-by-Birmingham-and-Solihull-NHS-Trust
Open published response
29 Feb 2016 Susan Beverley George · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 1
Absence of protocol or guidance for inpatient contact with emergency services View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Susan Beverley George · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of protocol or guidance for inpatient contact with emergency services
Wider context from the report “5. There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment/management.
” Source location Susan Beverley George · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop agreed staff protocol and guidance for responding when service users contact emergency services via 999, including risk review and safeguarding actions.
Verbatim wording from the response “5. There is no protocol/guidance on what steps to be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment and management.” Source location Susan-George-Response
Open published response
28 Jan 2016 Ronald VOLANTE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Failure to advise doctors or emergency services of changes in circumstances after the first call View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Magenta Living
Require call handlers to update emergency services about changes in a client’s circumstances and maintain contact until key holders or emergency services arrive.
View source
Magenta Living
Brief all trained community alarm call handlers on the revised procedures, record their understanding, and provide the updated procedure.
View source
Magenta Living
Address the revised procedures with new call-handling staff through the normal induction programme.
View source
Magenta Living
Monitor staff implementation of procedural changes through spot audits, call-recording reviews, data checks, and performance improvement measures.
View source See 1 more action
×
AI-generated summary
Ronald VOLANTE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Volante, who had ischaemic heart disease and an enlarged heart, called an out-of-hours alarm monitoring service for help on 5 November 2015. An ambulance was called, but information about his cardiac history was not passed on, and the service did not report a change in his condition when he stopped responding; he was found deceased when the ambulance arrived. The concerns focused on call-handler training, use of medical history, and communicating changes in circumstances to emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to advise doctors or emergency services of changes in circumstances after the first call
Wider context from the report “(2) Magenta Living Support Link were aware that there had been a change in Mr Volante’s presentation by 18.46 as he did not respond to the news that an ambulance was on the way – is this covered in induction training of call handlers with regard to advising a doctor or emergency service of a change in circumstances after the first call ?
” Source location Ronald VOLANTE · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require call handlers to update emergency services about changes in a client’s circumstances and maintain contact until key holders or emergency services arrive.
Verbatim wording from the response “Response to Coroner’s concerns” Source location 2016-0499-Response-by-Magenta-Living
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief all trained community alarm call handlers on the revised procedures, record their understanding, and provide the updated procedure.
Verbatim wording from the response “As a result of this change of procedure, all Magenta Living community alarmed trained call handlers were briefed with effect from 28ᵗʰ January 2016 as to this change and provided with a copy of the updated procedure that now includes this additional stage. As part of this discussion, staff confirmed their understanding of the new procedure which is recorded in their training record. This change of procedure will also be addressed with any new staff as part of their normal induction programme.” Source location 2016-0499-Response-by-Magenta-Living
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address the revised procedures with new call-handling staff through the normal induction programme.
Verbatim wording from the response “As a result of this change of procedure, all Magenta Living community alarmed trained call handlers were briefed with effect from 28ᵗʰ January 2016 as to this change and provided with a copy of the updated procedure that now includes this additional stage. As part of this discussion, staff confirmed their understanding of the new procedure which is recorded in their training record. This change of procedure will also be addressed with any new staff as part of their normal induction programme.” Source location 2016-0499-Response-by-Magenta-Living
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor staff implementation of procedural changes through spot audits, call-recording reviews, data checks, and performance improvement measures.
Verbatim wording from the response “However, in light of the Coroner’s concerns and appreciating that standards can always be improved, Magenta Living has incorporated a number of additions to the procedures manual as a result of the Coroner’s recommendations as set out above. Our standard practice, which has been followed in respect of these changes, is that any changes or amendments made to procedures are always quickly communicated to staff across the various shifts. This is carried out on a one-to-one basis and also at team level. For assurance purposes, Team Leaders and managers ensure staff implement any changes smoothly and effectively and measures are put in place to monitor this such as spot auditing, listening to call recordings, data checks. Any concerns are immediately brought to the attention of the member of staff and a performance improvement plan is established.” Source location 2016-0499-Response-by-Magenta-Living
Open published response
16 Sep 2015 Adil HABIB · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3
Failure to provide the attending ambulance service with the prison gate location View source Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers View source Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
London Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
London Ambulance Service NHS Trust
Request that prison staff state the ambulance access gate at the beginning of emergency calls.
View source
London Ambulance Service NHS Trust
Disseminate learning to emergency operations centre staff through the November Control Services Team Talk, requiring confirmation of the prison address to attend.
View source
London Ambulance Service NHS Trust
Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.
View source
London Ambulance Service NHS Trust
Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.
View source See 1 more action
×
AI-generated summary
Adil HABIB · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide the attending ambulance service with the prison gate location
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend . Whilst there is of course an issue for the prison in terms of offering the information , it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise?
” Source location Adil HABIB · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers
Wider context from the report “The prison officer who rang 999 from the control room did not immediately offer the LAS call handler the location of the prison gate to which the ambulance should be driven . I understand that your team has taken steps to remind all officers working in the control room that they must do this. I understand also that your team has an ongoing conversation with London Ambulance Service to enable best care to be given to those in the prison in need of paramedic attention.
” Source location Adil HABIB · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons . Perhaps that would be a useful exercise?
” Source location Adil HABIB · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request that prison staff state the ambulance access gate at the beginning of emergency calls.
Verbatim wording from the response “Following the inquest HMP Pentonville’s Head of Residence, ████████ has confirmed to the LAS’s Senior Quality Assurance Manager, ████████, that HMP Pentonville will continue to operate two prison gates. We requested that staff at HMP Pentonville are prompted to give the address of the prison gate ambulance staff are to attend at the beginning of the emergency call to the LAS.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate learning to emergency operations centre staff through the November Control Services Team Talk, requiring confirmation of the prison address to attend.
Verbatim wording from the response “To share the learning about the call to attend Mr Habib with EOC staff, the November Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked staff to confirm the address to attend when taking a call from any prison or young offender institution. Further, as is our practice, a copy of this reply will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors to share our learning with other ambulance services.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.
Verbatim wording from the response “The evidence submitted to the Court during the inquest outlined the actions the London Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main postal address in Caledonian Road for HMP Pentonville and the prison officer making the 999 call did not volunteer that a different prison gate was to be used. After being advised that a second gate was operated in Roman Way the address was added to the Gazetteer with accurate GPS information so that when selected, ambulance staff would be guided to the address by satellite navigation.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.
Verbatim wording from the response “With the assistance of the National Offender Management Service (NOMS) we have obtained a list of postal addresses for all prisons and young offender institutions in the UK and have been assured that the Local Safer Custody Leads have been asked to contact their respective local Ambulance Service Trusts to advise if there are additional or temporary gates to be used, either on a temporary or longer term basis, to those held by NOMS. We have made contact with the Safer Custody Lead for Greater London and established that aside from HMP Pentonville the thirteen prison and young offender institutions operate with a single vehicle access gate.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.