Recurring concern

Failure of ambulance information systems to transfer safety-critical clinical and operational information

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First reported 17 Apr 2014•Latest report 18 Jun 2025

Definition

What this concern includes

Includes failures in the dedicated ambulance-service information-transfer process where clinically important information from callers, hospitals, NHS 111, GPs or other relevant services is not conveyed to ambulance crews or treating clinicians in time for safe decision-making.

Not included

  • Excludes failures concerning information that is not clinically or operationally material to ambulance decision-making or patient transfer.
  • Excludes generic staffing, training, documentation or communication deficiencies that are not explicitly tied to the ambulance information-transfer process.
  • Excludes delays caused solely by hospital bed capacity, ambulance handover congestion or response-resource shortages when no information-transfer failure is identified.
  • Excludes failures in unrelated hospital, social-care or mental-health information systems.
Reports
12

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
12

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

East of England Ambulance Service NHS Trust3
Department of Health and Social Care2
Association of Ambulance Chief Executives1
College of Policing1
Devon & Cornwall Police1
Essex Partnership University NHS Foundation Trust1
Essex Police1
First Aid Cover Ltd1
HM Prison and Probation Service1
Joint Royal Colleges Ambulance Liaison Committee1
Medequip Assistive Technology Limited1
National Institute for Health and Care Excellence1
National Police Chiefs’ Council1
NHS Dorset Integrated Care Board1
NHS England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Northamptonshire

    AI-generated summary

    Andrew Crane · 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

    Andrew Crane suffered a cardiac arrest in his prison cell on 16 November 2016 and died despite resuscitation efforts. The report identified concerns about the response to his complaint of chest pain, including a lack of clarity about when a Code Blue should be called, and the failure to pass information about his lack of breathing and CPR to the ambulance service, which would have changed the response priority.

    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 pass updated patient condition information to the ambulance service

    Wider context from the report

    “(2) A Code Blue was called when Mr Crane collapsed, and at this stage an ambulance was called. After this call, it became clear that Mr Crane was not breathing and CPR was commenced, but this further information was not passed to the ambulance service. This information would have changed the priority of the ambulance response. ”

    Source location

    Andrew Crane · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Plymouth, Torbay & South Devon

    AI-generated summary

    Karen Lesley Peters · 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

    Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

    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 hospital clinicians and paramedics to coordinate transfer information

    Wider context from the report

    “3. Transfer of time critical patients I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team: (a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required; (b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way. I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard. I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue? I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance? ”

    Source location

    Karen Lesley Peters · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
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Data last updated 7 September 2026