5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Midlands Ambulance Service NHS Trust NEMS Community Benefit Services NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
NEMS Community Benefit Services
Review transferred EMAS cases, monitor monthly UCCH themes, escalate risks and participate in joint governance and After Action Reviews.
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NEMS Community Benefit Services
Improve CAD-to-Adastra transfer formatting, structure, legibility and visibility of prior NHS 111 clinical validation with system partners.
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NEMS Community Benefit Services
Implement BaRS in Adastra and migrate CAS and Out of Hours profiles from legacy ITK with required system configuration.
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NEMS Community Benefit Services
Review whether internal NEMS risk flags are needed when duplicated or poorly formatted information obscures clinical clarity.
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East Midlands Ambulance Service NHS Trust
Develop a technological solution with partner organisations to transfer complete patient information across urgent care services.
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East Midlands Ambulance Service NHS Trust
Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
View source
East Midlands Ambulance Service NHS Trust
Require clinicians to review available information and make all Category 3 transfers through the clinical push model.
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Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
Wider context from the report “2. There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS .
” Source location Jake Kieran Hartwright · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review transferred EMAS cases, monitor monthly UCCH themes, escalate risks and participate in joint governance and After Action Reviews.
Verbatim wording from the response “Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or automated ITK pathways. These pathways present lower risk because they are generated through NHS Pathways and meet defined criteria, and no further sepsis-related patient safety incidents have been identified since pathway changes in June 2025. Since 27th June 2025, NEMS implemented a pause on manually pushed calls while improvements were agreed with EMAS. Although manual pushes resumed on 21st July following assurance regarding CAD note quality and governance arrangement, NEMS confirms that it has not continued with manually pushed calls since 3rd December 2025. NEMS continues to proactively review cases transferred from EMAS and escalate concerns through joint governance structures, alongside close monitoring of monthly UCCH highlight reports to identify emerging themes” Source location Response from Nottingham Emergency Medical Service
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How this respondent action was interpreted
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PFD Monitor interpretation Improve CAD-to-Adastra transfer formatting, structure, legibility and visibility of prior NHS 111 clinical validation with system partners.
Verbatim wording from the response “NEMS has engaged in ongoing discussions with EMAS and OneAdvanced, the software provider responsible for Adastra (the electronic patient record system used by NEMS) to improve the formatting, structure and clarity of CAD-to-Adastra transfers. This has included identifying the duplication arising from the multiple message structure and formally requesting technical solutions to improve legibility and presentation of narrative information” Source location Response from Nottingham Emergency Medical Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement BaRS in Adastra and migrate CAS and Out of Hours profiles from legacy ITK with required system configuration.
Verbatim wording from the response “In addition, this process has generated learning and further improvement work between DHU 111 and NEMS in relation to the direct transfer of information from the 111 provider into NEMS systems will improve clinical safety for all patients. NEMS confirms that it has formally agreed with OneAdvanced to implement the Booking and Referral Standard (BaRS) within Adastra and is progressing this work in partnership with DHU. Following system configuration, a formal multi-agency project involving NEMS, DHU, OneAdvanced, NHS and the ICB Directory of Services team will oversee the migration of CAS and Out of Hours profiles from the legacy ITK framework to BARS, alongside necessary system configuration to ensure structured, complete and clearly displayed clinical information transfer.” Source location Response from Nottingham Emergency Medical Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether internal NEMS risk flags are needed when duplicated or poorly formatted information obscures clinical clarity.
Verbatim wording from the response “• Review whether additional internal NEMS risk flags should be applied where duplication or poor formatting obscures clinical clarity.” Source location Response from Nottingham Emergency Medical Service
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a technological solution with partner organisations to transfer complete patient information across urgent care services.
Verbatim wording from the response “The Trust recognises that, while the urgent care pathway performs well for most patients, those presenting with serious but not immediately life-threatening systemic illness may not be supported as effectively as required. To address this, the Trust has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision-making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.” Source location Response from East Midlands Ambulance Service NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
Verbatim wording from the response “In December 2025, the Trust upgraded its CAD system to ensure that all information captured during the initial 999 call is automatically transmitted to subsequent receiving systems. This enhancement has been fully tested with the Trust and NEMS and now supports the transfer of more comprehensive clinical information at the point of referral.” Source location Response from East Midlands Ambulance Service NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinicians to review available information and make all Category 3 transfers through the clinical push model.
Verbatim wording from the response “Historically, non-clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, the Trust implemented a significant change to operational practice:” Source location Response from East Midlands Ambulance Service NHS Trust
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How this respondent position was interpreted
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PFD Monitor interpretation Many technical solutions for reliable information transfer are outside NEMS’s direct control, limiting its ability to implement them independently.
Verbatim wording from the response “Whilst many of the technical solutions sit outside NEMS’ direct control, we remain committed to constructive system engagement to ensure that data transfer supports safe and informed clinical assessment across organisational boundaries.” Source location Response from Nottingham Emergency Medical Service
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How this respondent position was interpreted
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PFD Monitor interpretation Concerns about the urgent care pathway, CAD information, Category 3 call handling and transfer criteria should be addressed by EMAS, NEMS and the ICB.
Verbatim wording from the response “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.” Source location Response from NHS England
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28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to adequately record and accurately and completely convey symptom information View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lewis Aubrey GARFIELD · 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
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adequately record and accurately and completely convey symptom information
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” Source location Lewis Aubrey GARFIELD · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Siren to review ambulance pre-arrival patient information and reduce registration delays.
Verbatim wording from the response “| Improved discharge planning and boardround documentation.
May 2025 | Release to Respond Go live NGH. | Implement release to respond model with key escalation triggers to balance clinical risk across the organisation.
June 2025 | NyeBevan move to medicine specialty only and address backflow of patients with GIRFT. | Reduced LoS on NyeBevan with reduced medical outliers in surgical wards.
July 2025 | Use of Siren to review patient identifiable information from EMAS pre arrival. | Reduce delays associated with registration of patients into EPR.
Sept 2025 | Twice weekly system partner escalation calls for complex discharge support. | Improvement in super stranded position across UHN.
Oct 2025 | Cardiology Virtual Ward launched at NGH. | Reduce length of stay through virtual monitoring of heart failure patients who would otherwise meet criteria to reside.” Source location Response from University Hospitals of Northamptonshire
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PFD Monitor interpretation Introduce a NerveCentre pre-arrival screen using ambulance clinical histories to prepare handovers before arrival.
Verbatim wording from the response “Oct 2025 | Frailty SDEC go live NGH. | Frailty team based in medical SDEC for specialty assessment.
Oct 2025 | Trusted Assessor introduced at NGH. | Reduce discharge delays for patients returning to care homes.
Nov 2025 | Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. | Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand.
Dec 2025 | Introduction of nerve centre pre arrivals screen | Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.” Source location Response from University Hospitals of Northamptonshire
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The second call was upgraded because the patient’s condition deteriorated and accurate triage information became available.
Verbatim wording from the response “I have asked the SCAS legal team to provide you with copies of call recordings for the calls that were taken so that you can be satisfied that the information captured during the call triage was accurate. It is evident from the second 999 call that there had been a change and deterioration in Mr Garfield’s condition, and he had unfortunately fallen again after the first 999 call was made. The Emergency Call Taker was also able to obtain answers to the questions” Source location Response from South Central Ambulance Service
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8 Jul 2021 Nadeem Ahmed · Prevention of Future Deaths report East London
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Concerns raised 2
Failure to convey accurate and relevant clinical information from scene paramedics to the HEMS desk View source Failure of HEMS desk paramedics to request full clinical parameters View source
Linked responses
London Ambulance Service NHS Trust London's Air Ambulance
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
London Ambulance Service NHS Trust and London's Air Ambulance
Expand use of SBAR handovers when clinicians provide reports requesting additional specialist clinical support.
View source
London Ambulance Service NHS Trust and London's Air Ambulance
Prepare and issue a joint Medical Director’s bulletin explaining SBAR handover requirements, information content and practical application.
View source
London Ambulance Service NHS Trust and London's Air Ambulance
Circulate the SBAR bulletin to LAS clinical staff, LAA paramedics and operations-centre clinical staff through email, intranet, devices and management communications.
View source
London Ambulance Service NHS Trust and London's Air Ambulance
Incorporate SBAR handover content into LAS Core Skills Refresher training and scenario-based education.
View source
London Ambulance Service NHS Trust and London's Air Ambulance
Update training for operations-centre clinicians receiving clinical information to prompt an SBAR handover when needed.
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AI-generated summary
Nadeem Ahmed · 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
Nadeem Ahmed lacerated his brachial artery after putting his hand through a glass pane at his home on 8 February 2020. He suffered hypovolaemic shock, later cardiac arrest and multiple organ ischaemia, and died at the Royal London Hospital on 13 February 2020. The principal concerns were incorrect triage of emergency calls and failures to communicate accurate and relevant clinical information to the HEMS team, which denied him the opportunity to receive life-saving treatment before cardiac arrest.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to convey accurate and relevant clinical information from scene paramedics to the HEMS desk
Wider context from the report “At the time of communication between the LAS paramedic on scene and the paramedic on the HEMS dispatch desk, Mr Ahmed was in a state of hypovolemic shock. He had a very high pulse rate, a very high respiratory rate, had suffered a brief loss of consciousness and had a concerning pallor. This clinical picture was not conveyed to the HEMS desk. The paramedic on scene did not offer accurate and relevant clinical information. The paramedic on the HEMS desk requested only the GCS and not the full clinical parameters.
There may be an opportunity to improve communication between the HEMS dispatcher and paramedics on scene, by joint training and/or provision of a check-list for key clinical parameters to be shared. A senior HEMS clinician gave evidence at the inquest. He stated that video link communication might also aid in the transfer of relevant and accurate clinical information.
” Source location Nadeem Ahmed · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of HEMS desk paramedics to request full clinical parameters
Wider context from the report “At the time of communication between the LAS paramedic on scene and the paramedic on the HEMS dispatch desk, Mr Ahmed was in a state of hypovolemic shock. He had a very high pulse rate, a very high respiratory rate, had suffered a brief loss of consciousness and had a concerning pallor. This clinical picture was not conveyed to the HEMS desk. The paramedic on scene did not offer accurate and relevant clinical information. The paramedic on the HEMS desk requested only the GCS and not the full clinical parameters.
There may be an opportunity to improve communication between the HEMS dispatcher and paramedics on scene, by joint training and/or provision of a check-list for key clinical parameters to be shared. A senior HEMS clinician gave evidence at the inquest. He stated that video link communication might also aid in the transfer of relevant and accurate clinical information.
” Source location Nadeem Ahmed · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand use of SBAR handovers when clinicians provide reports requesting additional specialist clinical support.
Verbatim wording from the response “The SBAR tool was developed by the National Patient Safety Agency. The SBAR handover is designed to provide a structure for passing clinical information which is reproducible and aims to minimise risk of either incomplete information being passed or this being misinterpreted due to the ‘human factors’ experienced in a high pressure clinical situation. To provide further assurance around the information which is passed from clinicians on scene to inform the dispatch of further specialist resources we will expand the use of the SBAR handover tool for use in when such reports are provided. We are absolute that this enhanced process should not delay an early request for assistance where it is immediately apparent that such assistance is required but an SBAR should be provided once an initial assessment has occurred.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and issue a joint Medical Director’s bulletin explaining SBAR handover requirements, information content and practical application.
Verbatim wording from the response “We recognise the importance of ongoing refresher training to ensure staff are kept up to date and reminded of their training and the expected format and standard for such clinical handovers. To serve as a refresher to clinical staff and a checklist to refer to, a Medical Director’s bulletin has been jointly prepared by the LAS and LAA, attached for your reference. The Bulletin sets out the process for an SBAR clinical handover, the information to be included and practical advice on how to approach the handover to ensure best practice is consistently achieved. The bulletin also includes case study examples to demonstrate how the handover should work in practice.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the SBAR bulletin to LAS clinical staff, LAA paramedics and operations-centre clinical staff through email, intranet, devices and management communications.
Verbatim wording from the response “The bulletin will be circulated to all LAS clinical staff and LAA paramedics by email and will be available on the LAS intranet ‘The Pulse’ and accessible to staff through their personal issue IPads. The content of the bulletin will also be disseminated at sector level through management team communication. This bulletin will also be shared with clinical staff working within the operations centre including the LAA flight paramedics.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate SBAR handover content into LAS Core Skills Refresher training and scenario-based education.
Verbatim wording from the response “The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update training for operations-centre clinicians receiving clinical information to prompt an SBAR handover when needed.
Verbatim wording from the response “The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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Concerns raised 1
Failure to accurately transfer EPR information to patient information leaflets View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Thomas Rawnsley · 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
Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately transfer EPR information to patient information leaflets
Wider context from the report “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient.
” Source location Thomas Rawnsley · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed Patient Information Leaflet contents fully within the EPR.
Verbatim wording from the response “The Trust’s future intention is to ensure that contents of the PIL are fully embedded in the EPR and, when technological developments allow, the Trust will have the facility to email this entire record to the patient and their primary care provider.” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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How this respondent position was interpreted
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PFD Monitor interpretation The Trust will not undertake patient-leaflet photo audits because of practical difficulties and concerns that advance notice would skew results.
Verbatim wording from the response “The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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31 May 2019 Christopher Williams · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to communicate arranged admission-bed information to ambulance crews View source
This report raised 4 other concerns. 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. 3
EEAST
Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.
View source
EEAST
Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.
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EEAST
Share CAD information-recording and transmission best practice and solutions with other ambulance services.
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Christopher Williams · 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 Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate arranged admission-bed information to ambulance crews
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be addressed.
” Source location Christopher Williams · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.
Verbatim wording from the response “In the initial call the HCP called and asked for the patient to be conveyed to the Norfolk and Norwich University Hospital, the clinician requested for the patient to be taken to the Emergency Assessment Unit. When we received a 999 call from the property identifying that the patient’s condition had deteriorated the dispatcher allocated on the new call as it was of a higher priority, in line with 20180525 Ambulance System Indicators. Due to the dispatcher assigning to the new call it is apparent that information pertaining to the destination of the patient was omitted as the information is sent to the crew using data. We are in communications with the CAD supplier to make an alteration to the duplication process which would allow pertinent information to be transferred from the original call into the call which EEAST are “running on”.” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.
Verbatim wording from the response “Having a technical solution will minimise risk of human error. As an interim arrangement we will ask all dispatch staff to ensure that any pertinent information of this kind is transferred into the new call, until there is a technological resolution in place.” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share CAD information-recording and transmission best practice and solutions with other ambulance services.
Verbatim wording from the response “We are also working with our colleagues in other Ambulance Services who use the same CAD to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources.” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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10 Nov 2017 Darren James Powney · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Failure of dynamic risk assessments to facilitate ambulance crews requesting further information or clarification View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Darren James Powney · 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
Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of dynamic risk assessments to facilitate ambulance crews requesting further information or clarification
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification , as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” Source location Darren James Powney · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate Joint Operating Procedure and dynamic-risk-assessment guidance through staff briefings, memoranda, meetings, face-to-face sessions, induction and operational assurance activities.
Verbatim wording from the response “We have undertaken a range of measures to ensure staff understand the JOP and how it applies to them in practice as follows:” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
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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 Produce and install vehicle dashboard stickers prompting dynamic risk assessment before requesting police support.
Verbatim wording from the response “Undertaking a dynamic risk assessment is central to the work we do in delivering safe patient care as an Ambulance Trust. In order to reinforce to front line crews key areas to consider when informed that there is a flag relating to possible violence and aggression, a sticker has been developed to be placed in the front of the vehicle with prompts to consider prior to requesting police support. Following agreement with the relevant departments this is currently being produced and will be in all vehicles by the end of March 2018.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
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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 operational staff with statutory and mandatory dynamic-risk-assessment, conflict-resolution and breakaway training.
Verbatim wording from the response “Operational crews receive conflict resolution training, breakaway training and dynamic risk assessment training as part of Statutory and Mandatory training, this also includes use of the joint decision making model. The Trusts data currently shows that 88% of operational staff have received statutory and mandatory training.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.