Recurring concern

Failure to ensure effective paramedic clinical leadership and oversight

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First reported 8 May 2014•Latest report 18 Feb 2021

Definition

What this concern includes

Includes failures in paramedic arrangements for clinical leadership, supervision, risk assessment, professional challenge and oversight of safety-critical work, including detention-related decisions and oversight extending beyond clinical decisions to other operational aspects of paramedic work.

Not included

Excludes generic emergency-response leadership failures where paramedic leadership or oversight is not the identified unsafe condition.
Excludes generic paramedic staffing, training or experience deficiencies unless they directly result in inadequate paramedic leadership, supervision, risk assessment or challenge.
Excludes failures in clinical decisions made after effective paramedic leadership and oversight were available.
Excludes police, custody, nursing or other professional leadership concerns unless the assertion explicitly concerns the paramedic leadership and oversight function.

Reports: 2
Individual concerns: 4
Date range: 2014–2021
Stated actions: 6

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.

London Ambulance Service NHS Trust2

Association of Ambulance Chief Executives1

Metropolitan Police Service1

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.

18 Feb2021
Inner South London
Concerns raised2
1. Failure of paramedic leadership and risk assessment in detention situations
2. Failure of police and paramedics to obtain and exchange clinical advice on conveyance decisions
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.
Actions described in response 6
1. Action
  Provide Acute Behavioural Disturbance training to all clinicians joining the service.
  Stated by London Ambulance Service NHS TrustStated completed
2. Action
  Include Acute Behavioural Disturbance assessment, management and interagency communication in the next mandatory refresher training.
  Stated by London Ambulance Service NHS TrustStated planned
3. Action
  Develop a process to proactively dispatch a Clinical Team Manager or Incident Response Manager to suspected Acute Behavioural Disturbance calls involving police.
  Stated by London Ambulance Service NHS TrustStated in progress
1. Action
  Provide Acute Behavioural Disturbance education to Clinical Team Managers through two online learning sessions.
  Stated by London Ambulance Service NHS TrustStated planned
2. Action
  Share updated clinical guidelines digitally with clinicians through personally issued tablet devices.
  Stated by London Ambulance Service NHS TrustStated completed
3. Action
  Monitor and review Category 1 triage for suspected Acute Behavioural Disturbance, coordinate its use with police, and share upgrade information with emergency operations staff.
  Stated by London Ambulance Service NHS TrustStated in progress
Respondent positions 1
1. Position
  Once healthcare professionals attend, they take primary care of the casualty and officers follow their instructions regarding medical assistance.
  Stated by Metropolitan Police ServiceRedirects responsibility
AI-generated summary

Mr Kevin Clarke · 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 Kevin Clarke, a 35-year-old man with complex mental health problems, was found by police in a disturbed state on 9 March 2018, restrained, and later suffered a fatal cardiac arrest in an ambulance. The report identified concerns about inappropriate restraint, inadequate monitoring and dynamic risk assessment, unsuitable conveyance and positioning, insufficient clinical assessment, and weaknesses in training, leadership and supervision by police and ambulance staff.

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 paramedic leadership and risk assessment in detention situations
Wider context from the report
“2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic, who appeared to have insufficient seniority or experience to know what to do in a detention situation. Equally there was a lack of expectation or request by police for her input and advice. My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision, says she left it to them to decide, although preferring a safer method and then later changes her evidence. ”
Source location
Mr Kevin Clarke · Prevention of Future Deaths report
Page 3 · 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 of police and paramedics to obtain and exchange clinical advice on conveyance decisions
Wider context from the report
“2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic, who appeared to have insufficient seniority or experience to know what to do in a detention situation. Equally there was a lack of expectation or request by police for her input and advice. My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision, says she left it to them to decide, although preferring a safer method and then later changes her evidence. ”
Source location
Mr Kevin Clarke · Prevention of Future Deaths report
Page 3 · 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
Provide Acute Behavioural Disturbance training to all clinicians joining the service.

Verbatim wording from the response
“We provided evidence at the inquest to explain how our front line staff are trained and kept up to date via our Core Skills Refresher (CSR) training, which is a mandatory annual programme providing front line staff with three, eight hour training sessions per year. Since 2010 our crews have been trained in ABD and in recognition of how important ABD training is for ambulance clinicians, we have introduced ABD training as part of the syllabus for all clinicians joining the LAS and this will be incorporated for every new entrant who joins from April 2021.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 2 · response
Published 22 February 2021
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
Include Acute Behavioural Disturbance assessment, management and interagency communication in the next mandatory refresher training.

Verbatim wording from the response
“As we set out in evidence, we are committed to regularly increasing the knowledge and awareness of our front line staff on ABD and it will be included in our next CSR training which is due to be delivered in 2021/2022, subject to Covid-19 restrictions.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 2 · response
Published 22 February 2021
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
Develop a process to proactively dispatch a Clinical Team Manager or Incident Response Manager to suspected Acute Behavioural Disturbance calls involving police.

Verbatim wording from the response
“In order to further enhance the clinical leadership and experience on scene we are working through a process of change in order to pro-actively send either a Clinical Team Manager (or an Incident Response Manager) to calls where the Metropolitan Police Service or other Police service, report a case of suspected ABD. This must not distract from the timely response of the nearest available clinical resource, but will provide additional leadership on scene to support our frontline clinicians and enhance patient care.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 3 · response
Published 22 February 2021
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 Acute Behavioural Disturbance education to Clinical Team Managers through two online learning sessions.

Verbatim wording from the response
“In order to optimise this response, ABD training will be to be included in the package of education for our Clinical Team Managers (CTM) to further develop their core knowledge. There are two, two hour online learning sessions taking place before the end of April 2021. Staff attendance will be recorded and each CTM will have to report to confirm that they have completed the sessions.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 3 · response
Published 22 February 2021
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
Share updated clinical guidelines digitally with clinicians through personally issued tablet devices.

Verbatim wording from the response
“The LAS has established processes for sharing updated clinical guidelines digitally with our clinicians through the use of personally issued tablet devices to staff which alert staff to updated clinical guidelines. Further to this my Chief Medical Officer, who chairs the National Medical Directors Group is keen to ensure the regular update of these guidelines to reflect learning. ████████ our Clinical Practice Development Manager for Critical Care, who you heard from at the inquest, has joined the group which is developing and reviewing these guidelines and the learning from Mr Clarke’s death has been presented to the chair of the JRCALC guidelines group.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 4 · response
Published 22 February 2021
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
Monitor and review Category 1 triage for suspected Acute Behavioural Disturbance, coordinate its use with police, and share upgrade information with emergency operations staff.

Verbatim wording from the response
“We provided evidence at the inquest to detail our commitment to continue to monitor and review the use of ‘Category 1’ triage for potential ABD patients, which goes above the national position and demonstrates the importance the LAS place on ensuring the timeliest of response to this cohort of patients. The LAS will continue to work with the police to ensure this is used correctly to maximise benefit and will continue to highlight the need for accurate and concise sharing of information where ABD is suspected. The LAS will continue to ensure that the process for this upgrade of calls is shared within our Emergency Operations Centres.”

Source location
2021-0046-Response-from-London-Ambulance-Service-Redacted
Page 3 · response
Published 22 February 2021
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
Once healthcare professionals attend, they take primary care of the casualty and officers follow their instructions regarding medical assistance.

Verbatim wording from the response
“Officers and staff are instructed that once a healthcare professional is at the scene of the incident, the healthcare professional takes primary care of the casualty. The officer or member of staff should provide a handover to the healthcare professional using the pneumatic ATMIST (Age, Sex, Name, Time, Mechanism of injury, Injuries or Illness identified, Signs and Symptoms and Treatment given) which provides a framework for the information required by the healthcare professional. Officers and staff are instructed to call an ambulance because the casualty requires medical assistance beyond the first aid the officer or member of staff can provide. They are instructed that the paramedic may ask them to assist them when they arrive, and that they should follow their instructions.”

Source location
2021-0046-Response-from-MPS-Redacted
Page 2 · response
Published 22 February 2021
Open published response
8 May2014
Surrey
Concerns raised2
1. Limitation of supervising paramedic oversight to clinical decisions
2. Lack of a minimum experience requirement for supervising paramedics
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.

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

Rajesh Parkash · 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

Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.

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
Limitation of supervising paramedic oversight to clinical decisions
Wider context from the report
“3. Consideration should be given to ensuring that the role of a supervising paramedic extends to all aspects of their work, including driving, and is not limited to clinical decisions. ”
Source location
Rajesh Parkash · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a minimum experience requirement for supervising paramedics
Wider context from the report
“4. Consideration should be given to imposing some form of minimum experience requirement before a paramedic is able to act in the role of a supervising paramedic. ”
Source location
Rajesh Parkash · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure of paramedic leadership and risk assessment in detention situations

Failure of police and paramedics to obtain and exchange clinical advice on conveyance decisions

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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Limitation of supervising paramedic oversight to clinical decisions

Lack of a minimum experience requirement for supervising paramedics

Actions described in response 6

Respondent positions 1