Recurring concern

Unreliable categorisation and escalation of paramedic backup requests

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First reported 7 Mar 2022•Latest report 4 Mar 2025

Definition

What this concern includes

Includes failures in the dedicated process for recognising the urgency of paramedic backup, assigning or changing the backup priority, clinically reviewing challenges to categorisation and escalating requests when the patient's condition requires a higher-priority response.

Not included

  • Excludes initial ambulance emergency-call triage, dispatch allocation and general ambulance response-time failures where the deficiency is not specifically the categorisation or escalation of paramedic backup requests.
  • Excludes hospital-to-hospital transfer categorisation where the concern is the inter-hospital transfer process rather than backup requested by an attending paramedic crew.
  • Excludes generic clinical deterioration, communication or staffing deficiencies unless they directly impair paramedic-backup categorisation or escalation.
  • Excludes failures occurring after an appropriate backup priority has been assigned when the remaining problem is attendance, treatment or transport.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2022–2025

First to latest report issue date

Stated actions
1

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.

Nerams Ltd1
NHS England1
Recipient name withheld1
South East Coast Ambulance Service NHS Foundation Trust1

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. Sunderland

    AI-generated summary

    Jack Matthew Shields · 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

    Jack Matthew Shields, a 29-year-old man with extensive heart conditions, experienced shortness of breath at home and died on 28 April 2024 after deteriorating into cardiac arrest despite resuscitation attempts. The report raises concerns about the delayed ambulance response and the failure to recognise his deteriorating condition and request the highest-priority backup.

    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 correctly categorise and request the required priority of paramedic backup

    Wider context from the report

    “The evidence was clear that Jack’s condition at the time of the first ambulance arrival at 00:36am was such that a higher priority backup should have been requested. Jack was symptomatic of cardiogenic shock with descending blood pressures, shortness of breath, nausea and vomiting, and required the highest priority backup of Cat 1 (Peri Arrest). I am concerned that the crew should have recognised the deteriorating condition when considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a backup request may have led to rapid stabilisation and transportation to definitive care. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Jack Matthew Shields · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Circulate information to staff on available backup categories and the appropriateness of each.

    Verbatim wording from the response

    “Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.”

    Source location

    Response from The Nerams Group
    Page 1 · response
    Published 7 March 2025

    Open published response

  2. Surrey

    AI-generated summary

    Josephine Celia BARKER · 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

    Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

    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 follow up a paramedic request for recategorisation with clinical discussion

    Wider context from the report

    “12. The off-duty paramedic request re categorisation was not followed and the challenge to it did not lead to a clinical discussion. ”

    Source location

    Josephine Celia BARKER · Prevention of Future Deaths report
    Page 9 · concerns

    Open source report
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Data last updated 7 September 2026