Recurring concern

Unreliable ambulance-service clinical advice for callers

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First reported 3 Sep 2015•Latest report 17 Aug 2023

Definition

What this concern includes

Includes failures in ambulance-service clinical advice controls, including the content and application of advice, recognition of red flags, escalation recommendations, clinical-advisor competence assurance, auditing and policy safeguards where these directly affect the safety of advice given to callers.

Not included

Excludes generic ambulance response-capacity, dispatch, call-handling or hospital-handover failures when the clinical advice itself is not deficient.
Excludes failures limited to NHS 111 algorithms, MPDS pathways or ambulance call triage where those named systems provide the more specific supported boundary.
Excludes generic staff training, audit or communication deficiencies unless they directly impair ambulance-service clinical advice.
Excludes downstream treatment or attendance failures after safe ambulance-service advice has been provided.

Reports: 2
Individual concerns: 3
Date range: 2015–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Department of Health and Social Care1

Ministry of Housing, Communities and Local Government1

Sister of Kala Skinner1

South Western 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.

17 Aug2023
Manchester North
Concerns raised1
1. Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Revise the 111 SOP to remove self-conveyance exclusions except for Category 1 incidents and ask patients whether they can travel to hospital themselves.
  Stated by North West Ambulance Service NHS TrustStated completed
2. Action
  Communicate both revised 111 SOP requirements to staff through the 111 SharePoint site.
  Stated by North West Ambulance Service NHS TrustStated completed
Respondent positions 2
1. Position
  The Department of Health and Social Care will respond separately to the concern about ambulance-service advice for chest-pain patients.
  Stated by Ministry of Housing, Communities and Local GovernmentRedirects responsibility
1. Position
  No other ambulance services in England have blanket policies advising chest-pain patients not to travel independently to A&E.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Luke Matthew Brooks · 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 Matthew Brooks died unexpectedly at home on 25 October 2022 after approximately one week of cold/flu-like symptoms. The inquest recorded acute respiratory distress syndrome due to Aspergillus pneumonia. Concerns included the absence of a register of private landlords and an ambulance-service policy advising people with non-immediately life-threatening chest pain to attend A&E on their own.

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
Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone
Wider context from the report
“2. NWAS had a local policy of advising people who described symptoms of chest pain (not immediate life threatening) to attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services. ”
Source location
Luke Matthew Brooks · 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
Revise the 111 SOP to remove self-conveyance exclusions except for Category 1 incidents and ask patients whether they can travel to hospital themselves.

Verbatim wording from the response
“I will first address the former 111 policy relating to the exclusion of patients with chest pain from advice to make their own way to hospital. The revised policy now provides that all exclusions for self-conveyance, save for Category 1 incidents, will be removed, and patients will be asked if they can make their own way to hospital. These changes to the Standard Operating Procedure (SOP) were approved by the 111 SOP review group and then by the 111 Quality Business Group (QBG).”

Source location
Response from North West Ambulance Service
Page 1 · response
Published 25 June 2024
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
Communicate both revised 111 SOP requirements to staff through the 111 SharePoint site.

Verbatim wording from the response
“The SOP, reflecting both above changes, went live on 5th September 2023 and the changes were communicated to staff via the 111 SharePoint site (locally called OneSpace) in line with all SOP updates.”

Source location
Response from North West Ambulance Service
Page 1 · response
Published 25 June 2024
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 Department of Health and Social Care will respond separately to the concern about ambulance-service advice for chest-pain patients.

Verbatim wording from the response
“2. North West Ambulance Service (“NWAS”) had a local policy of advising people who described symptoms of chest pain (not immediate life threatening) not to attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services.”

Source location
Response from Department for Levelling up, Housing and Communities
Page 2 · response
Published 25 June 2024
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
No other ambulance services in England have blanket policies advising chest-pain patients not to travel independently to A&E.

Verbatim wording from the response
“The report raises concerns about the advice North West Ambulance Service NHS Trust (NWAS) gave to Mr Brooks which was to advise people who describe the symptoms of chest pain not to make their own way to A&E. Your report raised a concern that although NWAS had revised this policy other ambulance services may have similar policies.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 25 June 2024
Open published response
3 Sep2015
Avon
Concerns raised2
1. Failure to recognise critical clinical red flags
2. Failure to provide appropriate safety-focused clinical advice
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ms. Kala Michelle Skinner · 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

On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

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 critical clinical red flags
Wider context from the report
“(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
Source location
Ms. Kala Michelle Skinner · Prevention of Future Deaths report
Page 2 · concerns
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 provide appropriate safety-focused clinical advice
Wider context from the report
“(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
Source location
Ms. Kala Michelle Skinner · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Ambulance-service policies advising people with non-immediately-life-threatening chest pain to attend A&E alone

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Failure to recognise critical clinical red flags

Failure to provide appropriate safety-focused clinical advice

Actions described in response 2

Respondent positions 2