Recurring concern

Unreliable decisions about when ambulance attendance is required

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First reported 30 Aug 2013•Latest report 18 Mar 2026

Definition

What this concern includes

Includes failures in the process for recognising when ambulance attendance is required, distinguishing ambulance use from an out-of-hours GP or other service, clarifying who must make the request, defining the information and urgency required, and enabling prompt escalation in hospitals, prisons, care settings and comparable services.

Not included

Excludes delays in ambulance dispatch, attendance, travel or hospital handover after an appropriate ambulance request has been made.
Excludes general emergency-call handling, ambulance capacity, triage or response-time failures where the decision to request ambulance attendance is not the deficient control.
Excludes routine GP access, referral or clinical-assessment failures where no ambulance-escalation decision is involved.
Excludes generic staff training, communication or role-clarity deficiencies unless they directly impair deciding when ambulance attendance is required or who must request it.

Reports: 12
Individual concerns: 14
Date range: 2013–2026
Stated actions: 20

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.

Department of Health and Social Care2

Association of Ambulance Chief Executives1

Care UK Limited1

College of Policing1

Dorset Police1

Egg London1

G4S1

Gloucestershire Health and Care NHS Foundation Trust1

Herries Lodge1

HM Prison and Probation Service1

Home Office1

LNT Software1

London Ambulance Service NHS Trust1

London Central & West Unscheduled Care Collaborative Limited1

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.

5 Nov2014
Inner North London
Concerns raised2
1. Failure to request an ambulance promptly after a level one call
2. Confusion over requesting an ambulance after a level one call
This report raised 4 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
  Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
  Stated by Care UK LimitedStated completed
2. Action
  Review emergency care arrangements, including staff training and standardisation of emergency bags.
  Stated by Care UK LimitedStated in progress
AI-generated summary

William DAVIES · 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

William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.

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 request an ambulance promptly after a level one call
Wider context from the report
“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. 1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one. However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court. 2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. ”
Source location
William DAVIES · 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
Confusion over requesting an ambulance after a level one call
Wider context from the report
“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”
Source location
William DAVIES · 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
Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

Verbatim wording from the response
“• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

Source location
Response from Care UK
Page 1 · response
Published 5 November 2014
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
Review emergency care arrangements, including staff training and standardisation of emergency bags.

Verbatim wording from the response
“• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

Source location
Response from Care UK
Page 1 · response
Published 5 November 2014
Open published response
30 Aug2013
South Yorkshire (Western)
Concerns raised1
1. Confusion among staff about whether to call an ambulance or the out-of-hours GP service
This report raised 10 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

Mrs May Gibson · 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

Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

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 among staff about whether to call an ambulance or the out-of-hours GP service
Wider context from the report
“7) although not causative of Mrs Gibson’s death, there was confusion amongst staff as to the circumstances in which an ambulance should be called as opposed to contacting the out of hours GP service; ”
Source location
Mrs May Gibson · 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 to request an ambulance promptly after a level one call

Confusion over requesting an ambulance after a level one call

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

Concerns raised1

Confusion among staff about whether to call an ambulance or the out-of-hours GP service

Actions described in response 2