9 May 2025 Jake Samuel Lawler · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to recognise the significance of 12-lead ECG readings View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Jake Samuel Lawler · 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 Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community settings.
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× 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 the significance of 12-lead ECG readings
Wider context from the report “1. The inquest heard evidence that the significance of 12 lead ECG readings are regularly missed or misunderstood by clinicians which means that key warning signs are missed as in Jake’s case. It is unclear if this is a training issue or the way in which the machines report of volume. Without an improvement there will be further avoidable deaths
” Source location Jake Samuel Lawler · Prevention of Future Deaths report
Open source report
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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 Individual NHS Trusts and employers are responsible for staff competence and appropriate protocols following the death, rather than the Department.
Verbatim wording from the response “I note your concerns about training and national guidance. Individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice. We would expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Lawler. I note that Manchester University NHS Foundation Trust has considered how to improve both training and guidance as part of their Safety Improvement Plan, which they have shared with NHSE.” Source location 2025-0220- Response from Department of Health and Social Care
Open published response
Concerns raised 1
Deficiencies in ECG interpretation View source
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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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 Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” Source location Christian James Gabriel Hobbs · Prevention of Future Deaths report
Open source report
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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 Individual NHS Trusts and other employers are responsible for ensuring staff remain competent and capable in their areas of practice.
Verbatim wording from the response “On points F, K, and L, where you raise issues of workforce levels and training, individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice.” Source location Response from Department for Health and Social Care
Open published response
15 Nov 2023 Lauren Page Smith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2
Failure to correctly interpret 12 lead ECGs View source Lack of further ECG training after identified incorrect interpretation View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Health Services Safety Investigations Body University of Wolverhampton West Midlands Ambulance Service University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 15
Health Services Safety Investigations Body
Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.
View source
Health Services Safety Investigations Body
Review the exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Deliver CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Deliver ECG recognition and advanced life support sessions with Zoll Medical.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Deliver an in-person CPD event covering ECG signs and recognition.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Review ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Provide remedial ECG and acute coronary syndrome training to both clinicians through training school.
View source
West Midlands Ambulance Service University NHS Foundation Trust
Support a clinician’s attendance on a level-six ECG-in-practice university course.
View source
University of Wolverhampton
Review all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.
View source
University of Wolverhampton
Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.
View source
University of Wolverhampton
Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.
View source
University of Wolverhampton
Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.
View source
University of Wolverhampton
Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.
View source
University of Wolverhampton
Organise continuing professional development ECG masterclasses for registered paramedics.
View source See 12 more actions
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AI-generated summary
Lauren Page Smith · 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
Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.
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× 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 interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” Source location Lauren Page Smith · Prevention of Future Deaths report
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 Lack of further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” Source location Lauren Page Smith · Prevention of Future Deaths report
Open source report
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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 Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.
Verbatim wording from the response “On 20 December 2023, our Investigations and Insights team held an Intelligence Review Meeting; at this meeting we review all patient safety concerns and insights received into our organisation and consider them for further exploratory work. I would like to assure you that the Regulation 28 Report sent to us was considered in this meeting, along with other information available to us and I can confirm that further exploratory work is being undertaken in relation to the issues raised in your report.” Source location Response from Health Services Safety Investigations Body
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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 Review the exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.
Verbatim wording from the response “This exploratory work will be further reviewed by the end of January 2024 when we will consider the scope for an HSSIB investigation into issues related to Paramedic interpretation of ECGs in the community.” Source location Response from Health Services Safety Investigations Body
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 Deliver CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
Verbatim wording from the response “• There was a CPD day at Erdington hub alongside the Research team to provide presentation on STEMI clinical times article on ACS and the new JRCALC update, including the ambulance quality indicators and time from 999 call to inflation of a balloon in a specialist coronary catheter” Source location Response from West Midlands Ambulance 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 Deliver ECG recognition and advanced life support sessions with Zoll Medical.
Verbatim wording from the response “February 2023” Source location Response from West Midlands Ambulance Service
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 Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
Verbatim wording from the response “• Evening training session on ECGs and Resus skills delivered” Source location Response from West Midlands Ambulance Service
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 Deliver an in-person CPD event covering ECG signs and recognition.
Verbatim wording from the response “June 2023” Source location Response from West Midlands Ambulance Service
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 Review ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
Verbatim wording from the response “September 2023” Source location Response from West Midlands Ambulance Service
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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 remedial ECG and acute coronary syndrome training to both clinicians through training school.
Verbatim wording from the response “Both the clinicians are booked to attend training school for remedial training on the 1 December 2023. In addition to this ████████ will be meeting with the Trust’s Consultant Paramedic who is the Head of Clinical Care, ████████ to review and reflect on the ECG abnormalities as part of an additional self reflection request.” Source location Response from West Midlands Ambulance Service
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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 Support a clinician’s attendance on a level-six ECG-in-practice university course.
Verbatim wording from the response “Since the incident ████████ has also requested to attend a level 6 university course to further her knowledge on ECG’s. ████████ has been approved and supported by WMAS to attend a level 6 ECG in practice course, commencing in January 2024.” Source location Response from West Midlands Ambulance Service
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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 Review all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.
Verbatim wording from the response “The University understands and accepts without reservation that its training must be effective. We have reviewed all of the ECG training and assessment that takes place on the programme and are confident that our teaching fully covers the abnormalities found in the ECG in this case, the pathological implications of such findings, and the appropriate course of action to be taken.” Source location Response from University of Wolverhampton
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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 Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.
Verbatim wording from the response “▪ Evidence from the case will be presented to students to exemplify the potential harm from inadequate understanding of the ECG and the implications for the patient – we would welcome a copy of the ECG if this is possible” Source location Response from University of Wolverhampton
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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 Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.
Verbatim wording from the response “▪ Interpretation of 12-lead ECGs will be incorporated into one or more of the Objective Structured Clinical Examinations that students sit throughout their programme. This will supplement rather than replace the current assessments in practice.” Source location Response from University of Wolverhampton
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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 Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.
Verbatim wording from the response “▪ Members of the paramedic team are liaising with local coronary care units to obtain anonymised 12-lead ECG readings from real patients to further enhance the teaching” Source location Response from University of Wolverhampton
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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 Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.
Verbatim wording from the response “▪ A 12-lead ECG interpretation workbook will be added to the virtual learning environment for completion by students. Students who do not complete the activity will be followed up by their personal academic tutor” Source location Response from University of Wolverhampton
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 Organise continuing professional development ECG masterclasses for registered paramedics.
Verbatim wording from the response “▪ The University will organise continuing professional development ECG masterclasses to offer to registered paramedics” Source location Response from University of Wolverhampton
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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 Q-wave changes and AVR deflection are included in training but are not significant features of the high-level ECG competency described.
Verbatim wording from the response “Response
Q wave changes and AVR deflection does feature in our training but is not a significant feature, as this is high level ECG competency. The ECG auto diagnostic did identify an abnormal ECG and this should have been acted upon.” Source location Response from West Midlands Ambulance Service
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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 Student placement risks are ameliorated because a registered paramedic supervises students and remains responsible and accountable for patient care.
Verbatim wording from the response “████████ commenced her education at the University in June 2022, and is not due to complete her studies until January 2024. It is important to emphasise, that ████████ is not a registered paramedic and will not be eligible to apply for professional registration until such time as she has met all of the outcomes of her current programme of study. As a student, ████████ does not have all of the competencies and skills of a registered paramedic so would be working with a practice educator who is there to support and supervise her as she develops those competencies and skills. It is not expected that she would be making independent decisions on patient care whilst in her role as a student paramedic. The practice educator will always have the ability to override the decision of a student should they deem the proposed course of action to be sub-optimal for the patient.” Source location Response from University of Wolverhampton
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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 There was no evidence of provider-level failure in relation to Miss Lauren Page Smith’s death.
Verbatim wording from the response “Having carefully reviewed the information the trust has provided, we have concluded there is no evidence of provider level failing in relation to Miss Lauren Page Smith’s death. However, we did identify concerns that supported our inspection findings in relation to the serious incident investigation process, and in particular, the timeliness around addressing the training needs of the staff involved with Miss Lauren Page Smith’s care.” Source location Response from Care Quality Commission
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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 At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.
Verbatim wording from the response “It should also be noted that on the 6 January 2023, ████████ was working as an employee of WMAS and was not there in her student capacity. ████████ was working within the remit of an associate ambulance practitioner.” Source location Response from University of Wolverhampton
Open published response
21 Mar 2018 Barbara Johnson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to consider ECG machine printouts in clinical interpretation and judgment View source
Linked response
NHS Northern Care Alliance NHS Group
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AI-generated summary
Barbara Johnson · 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
Barbara Johnson was detained under Section 3 of the Mental Health Act and admitted to the Moorside Unit on 19 April 2017. She suffered a heart attack on 30 April 2017 and was pronounced deceased after resuscitation efforts. The principal concerns included gaps in physical observations and clinical review, deficiencies in handover and emergency-response equipment, and junior doctors’ failure to consider ECG machine printout abnormalities during interpretation.
Read the report on judiciary.uk
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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 consider ECG machine printouts in clinical interpretation and judgment
Wider context from the report “It is understood that Pennine Acute NHS Trust employed the junior doctors on the Moorside Unit at Tameside General Hospital. During the course of the inquest we heard evidence from ████████ regarding ECGs that he carried out on Barbara Johnson on the 19th April 2017 at the time of her admission to the Moorside Unit. A number of the doctors understandably did not recall carrying out the ECGs but formed the view from the records that the patient was moving at the time that the ECGs were performed. Thus, he explained, had an impact on the ECG although he was not able to explain the precise impact. At the top of 2 of the ECGs there was a printout from the machine which stated (inter alia) “T Wave abnormality”, “Possible anterolateral ischemia” and “abnormal ECG”. ████████ evidence was that regard would not be had to the printout summary at the top of the ECG and that the doctor would interpret the ECG himself. Whilst it was accepted that the printout is no substitute for a doctor’s interpretation, it did give cause for concern that junior doctors employed by the Trust were routinely ignoring the printout . It was of concern that the printout was not being considered and/or was not informing clinical interpretation and judgment .
” Source location Barbara Johnson · Prevention of Future Deaths report
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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 Administrative lead-employer responsibilities exclude the host hospital’s quality of care, training and day-to-day trainee supervision.
Verbatim wording from the response “I can advise that whilst the two junior doctors concerned were technically employed by Pennine Acute NHS Trust, who are the administrative lead employer for all junior doctors across Greater Manchester, Cumbria & Lancashire, they were placed at Tameside General Hospital who acted as the Host Trust. The Host Trust is responsible for the quality of care delivered to patients and direct supervision of a trainee on a day-to-day basis. Pennine Acute Trust, as the lead employer, are simply the administrative employer of the junior doctors, having responsibility for HR issues such as pay and sick leave, but are not responsible for the quality of training and care at a Host Trust.” Source location 2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
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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 host hospital is responsible for care quality and trainee supervision and has the power to address the reported concerns.
Verbatim wording from the response “I can advise that whilst the two junior doctors concerned were technically employed by Pennine Acute NHS Trust, who are the administrative lead employer for all junior doctors across Greater Manchester, Cumbria & Lancashire, they were placed at Tameside General Hospital who acted as the Host Trust. The Host Trust is responsible for the quality of care delivered to patients and direct supervision of a trainee on a day-to-day basis. Pennine Acute Trust, as the lead employer, are simply the administrative employer of the junior doctors, having responsibility for HR issues such as pay and sick leave, but are not responsible for the quality of training and care at a Host Trust.” Source location 2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
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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 administrative lead employer cannot implement changes at the host hospital because it lacks authority over care delivery and supervision.
Verbatim wording from the response “As such, I would suggest that Trafford General Hospital were responsible for the quality of the care provided to Barbara Johnson, and for the quality of care and direction supervision of the junior doctors. Therefore, Pennine Acute Trust is unable to implement change at Tameside General Hospital and we request that the Regulation 28 Report is amended and addressed to Tameside Hospital, who have the power to take action to address the concerns within your report.” Source location 2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
Open published response
28 Nov 2017 Mr Harold Chapman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Uncertainty in Holter interpretations and identification of NSVTs on traces View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr Harold Chapman · 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
Mr Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
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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 Uncertainty in Holter interpretations and identification of NSVTs on traces
Wider context from the report “(3) There was also a concern in respect of the holter interpretations and the presence or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new introduction and training regime for its specialist clinical fellows in the interpretation of holter readings.
” Source location Mr Harold Chapman · 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 Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.
Verbatim wording from the response “The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-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 Provide regular Holter-interpretation training for cardiomyopathy fellows through multidisciplinary meetings and consultant-supervised clinics.
Verbatim wording from the response “At RBHT all Holter monitor traces are interpreted and reported by trained electrophysiology technicians. Training for cardiomyopathy subspecialty fellows in Holter monitor interpretation is provided at regular MDT meetings and consultant supervised clinics, in addition to standard training for general cardiology trainees in rhythm interpretation.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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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 Multidisciplinary discussion is not required before ICD implantation because urgent cases can be referred directly to an implanting consultant.
Verbatim wording from the response “Abnormal Holter results are regularly discussed at MDT meetings. MDT discussion is not a pre-requisite for ICD implant at RBHT and urgent cases are referred directly to an implanting consultant who will list the patient as appropriate. Where MDT discussion is required (complex patients or those not meeting all criteria) this occurs within 2 weeks. The non-urgent waiting time for ICD implant from time of agreement to implant is of the order of 8-12 weeks. As a result of the PFD notice the inherited cardiac conditions care group are developing a standard operating procedure for notification of potentially significant arrhythmias.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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29 Nov 2016 Rex Brook Hall · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of formal testing of paramedics’ 12-lead ECG interpretation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Rex Brook Hall · 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
Rex Brook Hall died at Solihull Hospital on 28 July 2016 after presenting with right arm pain and atrial fibrillation and subsequently suffering a myocardial infarction and cardiac arrest. Paramedic ECGs showed ST elevation, but this was not recognised or reviewed on arrival at hospital. The principal concern was possible deficiencies in paramedic foundation training, including ECG interpretation, recognition of arm pain as an atypical sign of myocardial infarction, and identification of ST elevation.
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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 Lack of formal testing of paramedics’ 12-lead ECG interpretation
Wider context from the report “That there may be deficiencies in the foundation training of paramedics:
1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG ;
2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction; and
3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012).
” Source location Rex Brook Hall · 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 the paramedic standards of proficiency for possible amendments addressing the concerns raised.
Verbatim wording from the response “The SOPs for paramedics set out the knowledge, skills and abilities individuals must meet and maintain to register with us, and practice safely and effectively as a paramedic. These standards have been revised periodically, to ensure they remain relevant to current practice for the paramedic profession. In relation to the specific points regarding the training of the paramedics in question, the SOPs for paramedics include specific reference to the need for paramedics to:” Source location Response-by-HCPC
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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 Liaise with the College of Paramedics about whether the paramedic standards of proficiency should be amended.
Verbatim wording from the response “that all individuals are deemed eligible to apply with us for registration. Once registered, all registrants must continue to maintain their adherence to these standards to remain on the register, including showing evidence of their continuing professional development if audited. We are currently undertaking a review of the SOPs and will liaise with the College of Paramedics on the concerns raised in your report to explore whether any amendments should be made in this regard.” Source location Response-by-HCPC
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.