Recurring concern

Failure to provide timely direction and escort for arriving paramedics

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First reported 14 Dec 2015•Latest report 25 Nov 2024

Definition

What this concern includes

Includes failures of arrangements dedicated to receiving arriving paramedics and directing or escorting them promptly within care, treatment, care-home, sports or comparable premises, including designated personnel, access guidance, reception procedures and internal escort arrangements.

Not included

Excludes delays in ambulance dispatch, travel, hospital handover or treatment after paramedics have reached the correct clinical location.
Excludes failures to provide physical access to premises where the concern is gaining entry rather than directing or escorting paramedics after arrival.
Excludes generic staffing, training or communication deficiencies unless they directly impair the process for promptly directing or escorting arriving paramedics.
Excludes failures involving non-paramedic visitors, patients or emergency responders unless the assertion specifically concerns the arriving-paramedic direction and escort process.

Reports: 5
Individual concerns: 6
Date range: 2015–2024
Stated actions: 12

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.

Birmingham and Solihull Mental Health NHS Foundation Trust1

Gloucestershire Health and Care NHS Foundation Trust1

Goals Soccer Centres PLC1

Hampshire and Isle of Wight Healthcare NHS Foundation Trust1

Office of the Chief Coroner1

Recipient name withheld1

The Football Association1

W.E.Rawson Limited1

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.

25 Nov2024
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services
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 4
1. Action
  Agree a process with South Central Ambulance Service for updating emergency access information in its dispatch system.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
2. Action
  Provide South Central Ambulance Service with emergency meeting locations for all Trust inpatient units.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
3. Action
  Meet ambulance crews and escort them to the emergency location whenever they attend a Trust inpatient unit.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progress
1. Action
  Update emergency access information with South Central Ambulance Service annually or when additional inpatient units are added.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated planned
AI-generated summary

Dean John Mark Anthony BRAY · 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

Dean Bray died of acute heart failure on 29 December 2021 while in the seclusion room on Hamtun Ward. The report identified failures to adequately monitor and escalate his high respiratory rate, and concerns about the ability to make emergency calls from the observation room and delays accessing the seclusion area.

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 ensure that the ward's immediate access route is known and shared with emergency ambulance services
Wider context from the report
“Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House. ”
Source location
Dean John Mark Anthony BRAY · 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
Agree a process with South Central Ambulance Service for updating emergency access information in its dispatch system.

Verbatim wording from the response
“Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.”

Source location
Hampshire and IOW Healthcare NHS
Page 1 · response
Published 28 November 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
Provide South Central Ambulance Service with emergency meeting locations for all Trust inpatient units.

Verbatim wording from the response
“Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.”

Source location
Hampshire and IOW Healthcare NHS
Page 1 · response
Published 28 November 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
Meet ambulance crews and escort them to the emergency location whenever they attend a Trust inpatient unit.

Verbatim wording from the response
“In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.”

Source location
Hampshire and IOW Healthcare NHS
Page 2 · response
Published 28 November 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
Update emergency access information with South Central Ambulance Service annually or when additional inpatient units are added.

Verbatim wording from the response
“In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.”

Source location
Hampshire and IOW Healthcare NHS
Page 2 · response
Published 28 November 2024
Open published response
21 Feb2024
Gloucestershire
Concerns raised1
1. Lack of hospital guidance directing attending paramedics to the correct ward
This report raised 5 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.
Actions described in response 1
1. Action
  Issue and circulate guidance requiring staff to direct emergency-service responders to the appropriate ward.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
AI-generated summary

Severine Alexia Kelly · 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

Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.

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
Lack of hospital guidance directing attending paramedics to the correct ward
Wider context from the report
“A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital. This led to a delay in the paramedic attending on Severine. ”
Source location
Severine Alexia Kelly · Prevention of Future Deaths report
Page 1 · 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
Issue and circulate guidance requiring staff to direct emergency-service responders to the appropriate ward.

Verbatim wording from the response
“As with the 2nd issue, we have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice providing clarity with the actions that must be taken when emergency services have been called to attend a medical emergency. I can confirm that this has been circulated throughout the site and discussed at team meetings. The Practice Notice is included as Appendix 2.”

Source location
Response from Gloucestershire Health and Care NHS Foundation Trust
Page 2 · response
Published 23 February 2024
Open published response
26 Nov2018
Liverpool and the Wirral
Concerns raised2
1. Lack of training and drills for directing emergency services
2. Failure to ensure appropriate direction of arriving paramedics
This report raised 4 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.
Actions described in response 3
1. Action
  Circulate the Emergency First Aid Incident Procedure to all clubs to reinforce emergency roles and responsibilities.
  Stated by Goals Soccer Centres PLCStated completed
2. Action
  Finalise and implement the Goals Normal Operating Procedures and Emergency Action Plan across all clubs, incorporating emergency response procedures into regional audits.
  Stated by Goals Soccer Centres PLCStated planned
3. Action
  Provide all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.
  Stated by Goals Soccer Centres PLCStated planned
AI-generated summary

Jack Riding · 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 Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future 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
Lack of training and drills for directing emergency services
Wider context from the report
“(2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately. I have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but I have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like. I am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death, any delay of this kind presents a risk of future death. ”
Source location
Jack Riding · Prevention of Future Deaths report
Page 1 · 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 ensure appropriate direction of arriving paramedics
Wider context from the report
“(2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately. I have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but I have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like. I am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death, any delay of this kind presents a risk of future death. ”
Source location
Jack Riding · 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 the Emergency First Aid Incident Procedure to all clubs to reinforce emergency roles and responsibilities.

Verbatim wording from the response
“In addition to First Aid training, all staff are trained in ‘situational awareness’. This training includes medical emergencies. In particular, the training includes directing a member of staff to go and wait for an ambulance at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the casualty. In the case of Jack Riding this didn’t happen and we acknowledge that this part of the emergency was not handled in line with what Goals training. Since the incident, we have immediately circulated the Emergency First Aid Incident Procedure (appendix 13 in our response dated 18th November) to reaffirm the”

Source location
2018-0303-Responses
Page 5 · response
Published 13 December 2018
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 and implement the Goals Normal Operating Procedures and Emergency Action Plan across all clubs, incorporating emergency response procedures into regional audits.

Verbatim wording from the response
“In addition, the subsequent independent review of Health and Safety (commissioned following the incident) has provided a new draft document (Appendix 3) called “Goals Normal Operating Procedures and Emergency Action Plan 2019” which was created on the back of the updated “Goals First Aid risk assessment” (Appendix 9). The “Goals Normal Operating Procedures and Emergency Action Plan 2019” specifically includes (in section 2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it have been agreed and a timeline for rollout across the business is as follows:”

Source location
2018-0303-Responses
Page 6 · response
Published 13 December 2018
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 all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.

Verbatim wording from the response
“As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-played by all club staff and refreshed annually. Details of this can be found in the response to the training concern detailed in S5 (3).”

Source location
2018-0303-Responses
Page 6 · response
Published 13 December 2018
Open published response
15 Apr2016
Birmingham and Solihull
Concerns raised1
1. Failure to provide an escort for paramedics from reception to the Ward
This report raised 2 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.
Actions described in response 1
1. Action
  Amend the local protocol to nominate and identify a staff member to receive arriving paramedics.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
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 to provide an escort for paramedics from reception to the Ward
Wider context from the report
“2. The evidence was that when the Paramedics arrived in reception no-one was present to escort them to the Ward and only once they had arrived did a member of staff go to meet them. This is a source of obvious and dangerous delay. ”
Source location
Luke Christie AYRES · Prevention of Future Deaths report
Page 1 · 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
Amend the local protocol to nominate and identify a staff member to receive arriving paramedics.

Verbatim wording from the response
“On the matter of receiving the Paramedics at the Clinic, we have amended our local protocol to ensure that the nurse in charge nominates an individual to await arrival of the Paramedics. This individual will also wear a high visibility vest so that they are immediately identifiable upon arrival of the paramedic team. We believe that the improvements identified above will enhance our current arrangements for medical emergencies at Reaside Clinic and would like to thank you once again for bringing these matters to our attention.”

Source location
2016-0148-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 2 · response
Published 15 April 2016
Open published response
14 Dec2015
West Yorkshire Eastern
Concerns raised1
1. Failure of emergency-site access and wayfinding to expedite Ambulance arrival
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.
Actions described in response 3
1. Action
  Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.
  Stated by W.E.Rawson LimitedStated completed
2. Action
  Issue the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.
  Stated by W.E.Rawson LimitedStated planned
3. Action
  Provide flashlights in the security cabin for lookouts to attract emergency services’ attention.
  Stated by W.E.Rawson LimitedStated in progress
AI-generated summary

Paul David Whitehead · 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

Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

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 emergency-site access and wayfinding to expedite Ambulance arrival
Wider context from the report
“(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty. (2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager. (3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation. (4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes. These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur. Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty. ”
Source location
Paul David Whitehead · Prevention of Future Deaths report
Page 1 · 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
Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.

Verbatim wording from the response
“Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

Source location
Paul-Whitehead-Response
Page 1 · response
Published 14 December 2015
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 the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.

Verbatim wording from the response
“Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

Source location
Paul-Whitehead-Response
Page 1 · response
Published 14 December 2015
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 flashlights in the security cabin for lookouts to attract emergency services’ attention.

Verbatim wording from the response
“The revised Emergency procedures document now clearly states that the “lookouts” must be stationed at all of the access points to the site. Additionally we are ensuring that flash lights are kept in the security cabin which the lookouts are required to use as an aid for attracting the attention of the emergency services.”

Source location
Paul-Whitehead-Response
Page 2 · response
Published 14 December 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services

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.4

Concerns raised1

Lack of hospital guidance directing attending paramedics to the correct ward

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.1

Concerns raised2

Lack of training and drills for directing emergency services

Failure to ensure appropriate direction of arriving paramedics

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.3

Concerns raised1

Failure to provide an escort for paramedics from reception to the Ward

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.1

Concerns raised1

Failure of emergency-site access and wayfinding to expedite Ambulance arrival

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.3

Actions described in response 4

Actions described in response 1

Actions described in response 3

Actions described in response 1

Actions described in response 3