Recurring concern

Unreliable access to emergency communication

First to latest report 6 Jun 2014 — 15 Apr 2025

Reports that mention this concern: 46
Times this concern has been raised: 49
Stated actions linked to this concern: 51

What this concern includes

Includes failures of dedicated emergency communication facilities or arrangements where their unavailability, inaccessibility or unreliable operation can delay emergency assistance, including telephones, alarms, radios or equivalent means.

What is not included

Excludes inaccurate triage or categorisation of emergency calls.
Excludes failures to record, route or share information after a communication has been received unless the report directly identifies this as a failure of the emergency communication access arrangement.
Excludes ordinary customer-service or routine telephone-access problems without an emergency-response function.
Excludes hazards created by telephone equipment, such as ligature risks, where the concern is the equipment's physical safety rather than access to emergency communication.

Trends

Reports over time

Reports mentioning this concern, 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.

Department of Health and Social Care7

NHS England5

Association of Ambulance Chief Executives3

Health and Safety Executive3

Care Quality Commission2

HM Prison and Probation Service2

London Ambulance Service NHS Trust2

National Highways2

Winchester Prison2

Wolverhampton City Council2

Abbey Healthcare1

Appello Limited1

Bourne Leisure Limited1

Bow School1

British Heart Foundation1

Reports and published responses 46 reports

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

24 Oct2022
Birmingham and Solihull
Concerns raised1
1. Lack of a mechanism to broadcast a medical emergency by tannoy at the base
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kamil Iddrisu and Youngson Nkhoma · 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

Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

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 a mechanism to broadcast a medical emergency by tannoy at the base
Wider context from the report
“Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”
Source location
Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
Page 3 · concerns
Open source report
17 Oct2022
Hampshire, Portsmouth and Southampton
Concerns raised2
1. Absence of means for people in crisis to summon help
2. Lack of means for people experiencing mental health crisis to summon help at bridges
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Hampshire County Council
National Highways
Stated actions 3
1. National Highways
  Install four Samaritans crisis signs on the bridge parapets.
2. National Highways
  Add the location to the South East Network Needs list for future funding prioritisation.
3. National Highways
  Apply for future funding for a study into preventing future suicide events at the location.
Respondent positions 2
1. Hampshire County Council
  National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.
  Redirects responsibility
1. National Highways
  Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.
  Unable to act
AI-generated summary

Seth Curtis Palminder · 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

Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.

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 means for people in crisis to summon help
Wider context from the report
“2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance. There are no signs or signposting for mental health assistance or support (such as Samaritans). ”
Source location
Seth Curtis Palminder · 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 means for people experiencing mental health crisis to summon help at bridges
Wider context from the report
“5. Wider reports of self-harm incidents and fatalities are well known from ████████ ███████████████████████████████████████████████████████████████████████████ most of which do not have sufficient safety measures in place (as above) or means of summonsing help at a point of mental health crisis. ”
Source location
Seth Curtis Palminder · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Install four Samaritans crisis signs on the bridge parapets.

Verbatim wording from the response
“In September 2022, we installed four Samaritans “Crisis” signs on the inner faces of the parapets over both carriageways of the A3████████ road below. This features the short 6-digit number anyone in crisis can call from any phone 24 hours a day to reach a trained Samaritans volunteer.”

Source location
Response from National Highways
Page 2 · response
Published 20 October 2022
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
Add the location to the South East Network Needs list for future funding prioritisation.

Verbatim wording from the response
“We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

Source location
Response from National Highways
Page 2 · response
Published 20 October 2022
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
Apply for future funding for a study into preventing future suicide events at the location.

Verbatim wording from the response
“We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

Source location
Response from National Highways
Page 2 · response
Published 20 October 2022
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
National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.

Verbatim wording from the response
“The bridge at ████████ over the A3(████████) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3(████████) corridor, regardless of their primary usage. The ████████ bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used by pedestrians and cyclists.”

Source location
Response from Hampshire County Council
Page 1 · response
Published 20 October 2022
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
Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.

Verbatim wording from the response
“We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

Source location
Response from National Highways
Page 2 · response
Published 20 October 2022
Open published response
25 Aug2022
Black Country
Concerns raised1
1. Lack of reliable emergency communication facilities in the residents’ dining room
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Care Quality Commission
Hibiscus Housing Association Limited
Respondent positions 2
1. Care Quality Commission
  The CQC is not responsible for regulating the quality of Hibiscus House’s accommodation.
  Outside remit
1. Hibiscus Housing Association Limited
  The concern that no emergency alarm was available in the dining room is disputed because a functioning Care Link pull cord was installed there.
  Disputes the concern
AI-generated summary

Charles Evans · 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

Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

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 reliable emergency communication facilities in the residents’ dining room
Wider context from the report
“During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
Source location
Charles Evans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 CQC is not responsible for regulating the quality of Hibiscus House’s accommodation.

Verbatim wording from the response
“1. Hibiscus House is registered with CQC as a Domiciliary Care Agency (“DCA”) under the location name Hibiscus Domiciliary Care Agency and is operated by Hibiscus Housing Association Ltd to provide the regulated activity of ‘personal care’. Hibiscus DCA provides personal care and support to people who have learning disabilities, physical and mental health needs living in their own homes. Not everyone who uses DCA services receive the regulated activity of personal care. The CQC is not responsible for regulating the quality of the accommodation.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 4 November 2022
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 concern that no emergency alarm was available in the dining room is disputed because a functioning Care Link pull cord was installed there.

Verbatim wording from the response
“6. There was no emergency bell/alarm or telephone in the residents dining room. Staff were expected to use their mobile phone to call for help.”

Source location
Response from Hibiscus House
Page 3 · response
Published 4 November 2022
Open published response
16 Jun2022
West Sussex
Concerns raised2
1. Lack of a written procedure for making a 999 emergency call
2. Unavailability of an external phone line for emergencies
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Joseph MANNING · 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

James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

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 a written procedure for making a 999 emergency call
Wider context from the report
“e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available. ”
Source location
James Joseph MANNING · 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
Unavailability of an external phone line for emergencies
Wider context from the report
“d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed. ”
Source location
James Joseph MANNING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
23 Jun2021
West Yorkshire Eastern
Concerns raised1
1. Failure to check that vulnerable people have a working telephone for calling assistance or communicating
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Leeds City Council
Stated actions 2
1. Leeds City Council
  Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.
2. Leeds City Council
  Purchase a temporary pay-as-you-go mobile phone for discharge where a telephone, personal mobile or required telecare equipment is unavailable.
AI-generated summary

Netlyn Mae ROBINSON · 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

Netlyn Mae ROBINSON returned home on 2 October 2020 after adaptations for her reduced mobility, with three daily care visits. She was found the following morning at the dining table having choked on food. The report identified concerns about the absence of a falls alarm and working telephone, lack of risk assessment and checks for heating, water and smoke alarms, and insufficient processes for assessing whether her home was safe for her return.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to check that vulnerable people have a working telephone for calling assistance or communicating
Wider context from the report
“(2) The telephone line was not connected. There appeared to be no process in place to check that telephones are working and that a vulnerable person has the ability to call for assistance (emergency or otherwise) or communicate with friends/relatives. ”
Source location
Netlyn Mae ROBINSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.

Verbatim wording from the response
“Discharge Checklist/Crib Sheet (applies to points 1,2,3,4,6)”

Source location
2021-0219-Response-from-Leeds-City-Council_Published
Page 2 · response
Published 28 June 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
Purchase a temporary pay-as-you-go mobile phone for discharge where a telephone, personal mobile or required telecare equipment is unavailable.

Verbatim wording from the response
“MHU Emergency Telephone (applies to point 1)”

Source location
2021-0219-Response-from-Leeds-City-Council_Published
Page 3 · response
Published 28 June 2021
Open published response
3 Apr2020
Black Country
Concerns raised1
1. Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Edna May Davenport · 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

Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

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 alternative arrangements enabling residents with disabilities to call for assistance from their rooms
Wider context from the report
“(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”
Source location
Edna May Davenport · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Dec2019
West Sussex
Concerns raised1
1. Unavailability of responder telephone numbers within the call handling system
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
Unavailability of responder telephone numbers within the call handling system
Wider context from the report
“(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet). Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not. The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet. ”
Source location
John Michael WELLS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
28 Nov2019
Inner North London
Concerns raised1
1. Unavailability of cordless telephones for emergency calls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Christina Lawal · 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

Christina Lawal, who had type 2 diabetes and attended hospital regularly for dialysis, developed abdominal pain at home after returning from dialysis on 23 January 2019. She deteriorated, went into cardiac arrest shortly after paramedics arrived, and her death was confirmed at 23.05. The concerns included the absence of a cordless telephone for making emergency calls and the risk that ambulance triage callers may not provide accurate or updated information when they are not with the patient.

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
Unavailability of cordless telephones for emergency calls
Wider context from the report
“1) The care worker had to return to the main office at Duncan Court in order to make a 999 call as there was no cordless telephone available for her use. ”
Source location
Christina Lawal · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Oct2019
Dorset
Concerns raised1
1. Confusion over Police procedures for requesting Ambulance support
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Association of Ambulance Chief Executives
College of Policing
National Police Chiefs’ Council
Stated actions 2
1. College of Policing and National Police Chiefs’ Council
  Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.
2. College of Policing and National Police Chiefs’ Council
  Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Respondent positions 3
1. College of Policing and National Police Chiefs’ Council
  Chemical sedation and emergency-call categorisation are clinical matters for ambulance services, to which police officers defer.
  Redirects responsibility
1. College of Policing and National Police Chiefs’ Council
  Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
  Redirects responsibility
2. Association of Ambulance Chief Executives
  Information-passage arrangements between Police and Ambulance control rooms should be determined locally because technologies and working practices differ.
  Redirects responsibility
AI-generated summary

Douglas Paul Oak · 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

On 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.

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
Confusion over Police procedures for requesting Ambulance support
Wider context from the report
“ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room. I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST. ”
Source location
Douglas Paul Oak · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.

Verbatim wording from the response
“The College and NPCC have developed a PowerPoint presentation on ABD which describes the behavioural and physical signs of ABD and makes very clear the need for rapid clinical assessment/intervention. The ABD PowerPoint was developed with the benefit of clinical input and was last updated in July 2019.”

Source location
2019-0352-Response-by-College-of-Policing
Page 2 · response
Published 22 November 2019
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 standardised ABD presentation and training template for police and ambulance control-room staff.

Verbatim wording from the response
“The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.”

Source location
2019-0352-Response-by-College-of-Policing
Page 4 · response
Published 22 November 2019
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
Chemical sedation and emergency-call categorisation are clinical matters for ambulance services, to which police officers defer.

Verbatim wording from the response
“The other matters within this area for concern (chemical sedation and categorisation of calls) are clinical matters in which police officers would not be directly involved other than to ensure that the ambulance service has access to the information that it needs. Police officers would defer to ambulance colleagues in these matters.”

Source location
2019-0352-Response-by-College-of-Policing
Page 3 · response
Published 22 November 2019
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
Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.

Verbatim wording from the response
“The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues with their local emergency service providers.”

Source location
2019-0352-Response-by-College-of-Policing
Page 5 · response
Published 22 November 2019
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
Information-passage arrangements between Police and Ambulance control rooms should be determined locally because technologies and working practices differ.

Verbatim wording from the response
“AACE understand the cultural and practical barriers raised by the NPCC and accept that direct communication from the Police Officer on scene may not always be practicable. Ambulance trusts have locally agreed arrangements for the passage of information between Police and Ambulance control rooms. This is best determined at a local level due to differing technologies and working practices.”

Source location
2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
Page 3 · response
Published 22 November 2019
Open published response
14 Oct2019
Inner North London
Concerns raised1
1. Failure to ensure first aider knowledge of ambulance-summoning arrangements
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

César Cuauhtémoc González Barrón · 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

César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to 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 to ensure first aider knowledge of ambulance-summoning arrangements
Wider context from the report
“2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it. She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance. She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building. ”
Source location
César Cuauhtémoc González Barrón · Prevention of Future Deaths report
Page 2 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of a mechanism to broadcast a medical emergency by tannoy at the base

Concerns raised2

Absence of means for people in crisis to summon help

Lack of means for people experiencing mental health crisis to summon help at bridges

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of reliable emergency communication facilities in the residents’ dining room

Linked responses

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Lack of a written procedure for making a 999 emergency call

Unavailability of an external phone line for emergencies

Concerns raised1

Failure to check that vulnerable people have a working telephone for calling assistance or communicating

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms

Concerns raised1

Unavailability of responder telephone numbers within the call handling system

Concerns raised1

Unavailability of cordless telephones for emergency calls

Concerns raised1

Confusion over Police procedures for requesting Ambulance support

Linked responses

Stated actions 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.3

Stated actions 3

Respondent positions 2

Respondent positions 2

Stated actions 2

Stated actions 2

Respondent positions 3