Recurring concern

Unreliable emergency arrangements for assisting third parties

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First reported 10 Jul 2018•Latest report 16 Jun 2026

Definition

What this concern includes

Includes deficiencies in explicitly identified emergency protocols, policies, guidance, training or inter-agency arrangements for assisting a third party, including assessing deterioration, arranging suitable supervision or care, initiating emergency attendance, coordinating agencies and defining responsibility when the third party is not the original service user or caller.

Not included

Excludes generic emergency response, communication or safeguarding deficiencies where no third-party assistance context is identified.
Excludes ordinary care or medical assessment failures concerning the direct service user when no third party requires assistance.
Excludes downstream ambulance, police or clinical response failures after responsibility and the required emergency arrangement have been clearly established.
Excludes unrelated multi-agency protocols, such as event emergency arrangements, unless they specifically concern emergency assistance to a third party.

Reports: 3
Individual concerns: 3
Date range: 2018–2026
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.

Association of Ambulance Chief Executives2

NHS England2

South East Coast Ambulance Service NHS Foundation Trust2

Appello Careline Limited1

Appello Limited1

College of Policing1

Dyfed-Powys Police1

NHS Pathways1

South Western Ambulance Service NHS Foundation Trust1

TSA – The Voice of Technology Enabled Care1

Wiltshire Police1

Worthing Homes 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.

16 Jun2026
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of careline policy, guidance and training for third-party emergencies
This report raised 8 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 2
1. Action
  Update operator training materials to clarify handling of assistance requests concerning people other than the service user.
  Stated by Appello Careline LimitedStated planned
2. Action
  Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
  Stated by TSAStated planned
Respondent positions 5
1. Position
  Existing procedures already require appropriate assistance where someone other than the service user needs help.
  Stated by Appello Careline LimitedExisting arrangements considered sufficient
1. Position
  Existing procedures, training, auditing and continuous improvement provide a robust framework for managing the identified risks.
  Stated by Appello Careline LimitedExisting arrangements considered sufficient
2. Position
  The organisation cannot offer a view on guidance for careline operators handling assistance calls made on behalf of another person.
  Stated by Association of Ambulance Chief ExecutivesUnable to act
3. Position
  The organisation and its members cannot provide the clinical governance needed for a telecare decision-support tool.
  Stated by Association of Ambulance Chief ExecutivesUnable to act
4. Position
  Responsibility for continuing telecare decision-support-tool work was transferred to NHS England's stewardship.
  Stated by Association of Ambulance Chief ExecutivesRedirects responsibility
AI-generated summary

Derek Thomas Burt · 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

Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.

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 careline policy, guidance and training for third-party emergencies
Wider context from the report
“2) I also heard from the careline centre manager that Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves. It was good to learn that both careline operators did respond positively to the cry for help from Mrs Burt. I remained concerned, however, that there is no policy or guidance available for operators to cover this type of emergency or life threatening situation and no training has yet been devised to learn from the unusual circumstances that occurred here. ”
Source location
Derek Thomas Burt · Prevention of Future Deaths report
Page 4 · 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
Update operator training materials to clarify handling of assistance requests concerning people other than the service user.

Verbatim wording from the response
“Concern 2 Appello Careline Limited intends to update its operator training materials to clarify that calls may be received where assistance is sought for another person, for example a household member or visitor.”

Source location
Response from Appello Careline Operations Director
Page 5 · response
Published 14 August 2026
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
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.

Verbatim wording from the response
“Opportunities exist to strengthen guidance and operational procedures in these areas to help reduce the risk of similar issues occurring in the future and these will be addressed through future TEC Quality CPD e-learning programme and through strengthened QSF criteria for all certified TEC Monitoring Auditees to ensure the quality of TEC call monitoring and response.”

Source location
Response from Telecare Services Association
Page 8 · response
Published 14 August 2026
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
Existing procedures already require appropriate assistance where someone other than the service user needs help.

Verbatim wording from the response
“Concern 2 Appello Careline Limited’s existing procedures already require operators to arrange appropriate assistance based on the information provided, regardless of whether the person in need is the service user. Assistance was arranged in accordance with those procedures in this case.”

Source location
Response from Appello Careline Operations Director
Page 3 · response
Published 14 August 2026
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
Existing procedures, training, auditing and continuous improvement provide a robust framework for managing the identified risks.

Verbatim wording from the response
“Appello Careline Limited considers that its existing procedures, supported by ongoing training, audit and continuous improvement processes, provide a robust framework for managing the risks identified in this case.”

Source location
Response from Appello Careline Operations Director
Page 4 · response
Published 14 August 2026
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 organisation cannot offer a view on guidance for careline operators handling assistance calls made on behalf of another person.

Verbatim wording from the response
“3. This specific issue is not one AACE is able to offer a view upon.”

Source location
Response from Association of Ambulance Chief Executives
Page 5 · response
Published 14 August 2026
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 organisation and its members cannot provide the clinical governance needed for a telecare decision-support tool.

Verbatim wording from the response
“The critical element of our work with them relates to the development of a decision-support tool. TSA did not have the appropriate level of clinical governance to support this, and AACE and its members are not in a position to offer this.”

Source location
Response from Association of Ambulance Chief Executives
Page 6 · response
Published 14 August 2026
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
Responsibility for continuing telecare decision-support-tool work was transferred to NHS England's stewardship.

Verbatim wording from the response
“Following liaison with NHS England, it was agreed that this work would continue under their stewardship. In 2023 the TSA published their Decision Support Tool Guidance, and a TEC Call Handling Support Tool.”

Source location
Response from Association of Ambulance Chief Executives
Page 6 · response
Published 14 August 2026
Open published response
9 Dec2019
West Sussex
Concerns raised1
1. Different ambulance-call handling for third-party callers
This report raised 7 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

John Michael WELLS · 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

John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.

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
Different ambulance-call handling for third-party callers
Wider context from the report
“(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient. The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone. From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA. ”
Source location
John Michael WELLS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
10 Jul2018
Wiltshire and Swindon
Concerns raised1
1. Absence of third-party care and deterioration provisions in the 2017 agreement
This report raised 7 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

Eugeniusz Niedziolko · 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

Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.

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
Absence of third-party care and deterioration provisions in the 2017 agreement
Wider context from the report
“e) 2009 & 2017 MULTI PART AGREEMENT (copies enclosed) - As regards the Agreement in 2009, I noted with interest insofar as the Ambulance protocol was concerned that a risk of deterioration should be assessed and that the patient should be left in the care of a 3rd party, with advice on seeking medical assistance later if required. I am concerned and have aired as to why this is absent from the 2017 Agreement and also I am concerned as to why consideration is not given for a similar provision being incorporated into the police protocol in the 2017 Agreement. Such a measure appears to be eminently sensible as a matter of common sense. ”
Source location
Eugeniusz Niedziolko · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of careline policy, guidance and training for third-party emergencies

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.5

Concerns raised1

Different ambulance-call handling for third-party callers

Concerns raised1

Absence of third-party care and deterioration provisions in the 2017 agreement

Actions described in response 2

Respondent positions 5