Recurring concern

Unreliable emergency arrangements for assisting third parties

First to latest report 10 Jul 2018 — 16 Jun 2026

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

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.

What is 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 and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Sussex, Brighton and Hove

    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
  2. West Sussex

    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
  3. Wiltshire and Swindon

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026