23 Jan 2026 Jean GROVES · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to provide emergency responders with access details for vulnerable patients View source
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Jean GROVES · 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
Jean Groves, who had a complex health background, became unwell with diarrhoea and vomiting and was later found deceased at home on 24 March 2025 from excessive bleeding related to her underlying health condition. The concern was that emergency responders may not receive access details for vulnerable patients when supporting the ambulance service under the NHS “Access to the Stack” initiative, potentially leading to future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide emergency responders with access details for vulnerable patients
Wider context from the report “I have concerns that if emergency responders are not being provided with access details for vulnerable patients when providing support to the ambulance service under the NHS “Access to the Stack” initiative , this may lead to future deaths.
” Source location Jean GROVES · Prevention of Future Deaths report
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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 Confirm procedures for recording and communicating property access information when provided.
Verbatim wording from the response “As part of this review we have:” Source location Response from Careline365
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review onboarding and data-capture processes to ensure prompts exist for recording known access arrangements.
Verbatim wording from the response “As part of this review we have:” Source location Response from Careline365
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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 Consider how access arrangements should be recorded and communicated within multi-agency emergency response pathways.
Verbatim wording from the response “As part of this review we have:” Source location Response from Careline365
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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 Referrals without recorded access details are declined and returned to EEAST under the existing process.
Verbatim wording from the response “As no access details were recorded on the system, the referral was subsequently declined and returned to EEAST. If we have no access details recorded on the A2S referral portal or the Service Users Social Care record our process is to decline the referral and return to Stack. In accordance with our usual process, details of declined referrals should be recorded on the Service User’s Social Care record. Unfortunately, in this instance, no such record was created. This was an internal recording error; it had no impact on our decision making.” Source location Response from Norfolk County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The records contained no property access details, and the ARC accurately reported their absence when the ambulance service asked.
Verbatim wording from the response “Ms Groves’ telecare account formed part of a portfolio of service users transferred to Careline365 from Saffron Housing Association during a bulk migration of monitoring services. The dataset transferred to Careline365 contained standard ARC account information, including personal details, medical information and emergency contacts where available. Subsequent review confirms that no key safe or property access details were included for Ms Groves in the migrated records and were therefore not recorded on her account.” Source location Response from Careline365
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Careline365 does not install or control property access arrangements unless specifically requested by the service user or referring authority.
Verbatim wording from the response “Careline 365 do not install or control property access arrangements unless specifically requested by the Service User or the referring authority, in this case Norfolk County Council.” Source location Response from Careline365
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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 Emergency services determine how to gain property access when Careline365 has no access arrangements recorded.
Verbatim wording from the response “Where no access arrangements are recorded, the ARC escalates the incident to the emergency services and provides all available information. The emergency services then determine how to gain access.” Source location Response from Careline365
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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 ambulance service is responsible for call categorisation and decisions to refer cases through the community response pathway.
Verbatim wording from the response “Careline365 does not operate or control the NHS “Access to the Stack” pathway. Our role was to respond to the alarm activation and escalate the incident to 999 due to the uncertainty regarding injury.” Source location Response from Careline365
Open published response
Concerns raised 1
Failure to make multi-agency familiar face plans easily accessible to ambulance first responders View source
Linked response
North East Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
North East Ambulance Service NHS Foundation Trust
Require ambulance dispatch staff to verbally notify crews of flagged cases and obtain acknowledgement.
View source
North East Ambulance Service NHS Foundation Trust
Use an internal task and finish group to assess flag-access processes, explore improvements, and update the existing process.
View source
North East Ambulance Service NHS Foundation Trust
Progress supplier consultation and internal governance assessment of proposed technical changes for direct crew access to special patient notes and flags.
View source
North East Ambulance Service NHS Foundation Trust
Cascade guidance to emergency ambulance crews on accessing additional patient information and using appropriate systems.
View source
North East Ambulance Service NHS Foundation Trust
Work with regional partners to develop more effective centralised systems for sharing flags and care plans.
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Sophie Jayne Wilson · 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
Sophie Jayne Wilson was found deceased at home on 2 July 2023 following an overdose, after she had disclosed the overdose to the Crisis team and declined assistance from ambulance responders. The principal concerns were that responders were unaware of her multi-agency familiar face plan and that crucial information about capacity, risk and how to support her was not readily accessible to them.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make multi-agency familiar face plans easily accessible to ambulance first responders
Wider context from the report “(1) Although I received reassurance following the internal investigation that actions have been completed and lessons learnt in relation to this death, I remain concerned about the fact that the ambulance crew and paramedic were entirely unaware of the familiar faces plan in place for Sophie which contained crucially important information pertinent as to how best to assist her, secure her engagement and in relation to issues of both capacity and risk . I was told in evidence that the difficulty related to a data limit upon the electronic devices utilised by NEAS, and that therefore there should be a flag on electronic communications and that the control room would need to be contacted to obtain the additional information. NEAS were a signatory to the multi agency familiar face plan in this case which applies to them as well as a number of other agencies and was designed to assist in supporting the deceased and to reduce the risk of harm.
(2) I am concerned that the information was not seen by the ambulance crew and paramedic who attended , and I am not reassured that it will be available to first responders on future occasions as it seems that the limits of the technology require the ambulance crew or paramedic to spot the flag and to contact the control room, presumably for a verbal account of the information only . I am concerned that in an emergency situation and when services are under such pressure that crucial information, such as a multi agency familiar face plan is not easily accessible to those attempting to offer assistance to some of the most vulnerable people in society.
” Source location Sophie Jayne Wilson · Prevention of Future Deaths report
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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 Require ambulance dispatch staff to verbally notify crews of flagged cases and obtain acknowledgement.
Verbatim wording from the response “In considering the fact the ambulance crew were unaware of the familiar faces plan in this case, in respect to terminology we would classify a familiar faces plan within the wider context of a special patient note or a flag. As an interim solution we have instructed our ambulance dispatch team to verbally notify staff of any ‘flags’ placed against each case. This will enable an interaction and to seek an acknowledgement that ambulance crews have seen the ‘flag’ whilst providing an opportunity to share any additional information depending upon the type of ‘flag’.” Source location Response from North East Ambulance Service
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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 Use an internal task and finish group to assess flag-access processes, explore improvements, and update the existing process.
Verbatim wording from the response “To progress the medium-term improvement work, we have created an internal task and finish group who are tasked with assessing the current process and exploring options to improve the systems and process relating to ‘special patient notes’ or simply ‘flags’ and the ability of ambulance crews to directly access this information. I can confirm that the group held the first meeting on 1st October 2024 with further meetings being scheduled to progress with the outputs from the group. It is important to note that other workstreams are linked with the task and finish group which will help triangulate the wider system improvements I have described.” Source location Response from North East Ambulance Service
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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 Progress supplier consultation and internal governance assessment of proposed technical changes for direct crew access to special patient notes and flags.
Verbatim wording from the response “Linked with these medium-term developments we have already commenced consultation with our software supplier in respect of the feasibility and timescales associated with this development. Initial engagement has been positive, and we have obtained a quote to undertake the technical development work, and a quote has now been obtained with funding identified internally. The changes are currently being considered via internal governance routes to assess potential risks and provide assurances in respect to the impact of the proposed changes. Once the NEAS subject matter expert groups, Change Approval Board and Operational Management Group, have granted approval the Executive Management Group will consider the combined expert opinions and approve the changes.” Source location Response from North East Ambulance Service
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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 Cascade guidance to emergency ambulance crews on accessing additional patient information and using appropriate systems.
Verbatim wording from the response “In respect to access to other clinical records, NEAS ambulance crews also have access to the GP summary information (via GP Connect) and the Great North Care Record, which is a region wide shared care record providing information associated with patients from all providers in the region. Linked with my response to your first concern, I have explained that we have instructed our ambulance dispatch teams to verbally notify staff of any ‘flags’ placed against each case. Alongside this process we will be cascading information to emergency ambulance crews in respect to the importance of accessing additional information and using the appropriate systems.” Source location Response from North East Ambulance Service
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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 Work with regional partners to develop more effective centralised systems for sharing flags and care plans.
Verbatim wording from the response “It is important to mention that both information sharing platforms, GP Connect and Great North Care Record, do not presently have full patient details or care plan documents from all providers. The North East and North Cumbria Integrated Care Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will continue to work with wider system partners to develop more effective centralised means of region wide flagging and care plan sharing.” Source location Response from North East Ambulance Service
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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 vehicle MDT is unsuitable for receiving or displaying documents because of its purpose and technological limitations.
Verbatim wording from the response “Whilst we are confident that this covers messaging requirements, an additional technical control will be introduced to split any messages into continuation messages should any exceed the specified character limit. In considering the above explanation the MDT within the vehicle is not suitable or an appropriate device to receive documents and/or for crews to use this for reading documentation, given the limitations even with the upgraded technology and software. The MDT serves a specific purpose which is predominately for satellite mapping/navigation and sending critical alerts to staff. We will go onto explain the rationale and our alternative solution to ensure staff have access to additional clinical records and information directly in the response to the second concern.” Source location Response from North East Ambulance Service
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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 Dispatch staff may be unable to contact crews about flags during periods of extreme pressure while balancing other priority communications.
Verbatim wording from the response “It is however important to note that in times of extreme pressure our dispatch staff may not always be able make this contact, whilst balancing other priority contact with crews.” Source location Response from North East Ambulance Service
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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 Integrated Care Board is leading regional work to improve centralised flagging and care-plan sharing across providers.
Verbatim wording from the response “It is important to mention that both information sharing platforms, GP Connect and Great North Care Record, do not presently have full patient details or care plan documents from all providers. The North East and North Cumbria Integrated Care Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will continue to work with wider system partners to develop more effective centralised means of region wide flagging and care plan sharing.” Source location Response from North East Ambulance Service
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18 Apr 2023 Patrick Soames · Prevention of Future Deaths report South London
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Concerns raised 1
Lack of a national risk-flagging system for previous self-harm attendances View source
This report raised 3 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.
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AI-generated summary
Patrick Soames · 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
Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.
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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 national risk-flagging system for previous self-harm attendances
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system : for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up .
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history .
” Source location Patrick Soames · Prevention of Future Deaths report
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19 Jan 2021 Vhari Ingall · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 2
Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information View source Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care Quality Commission
Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.
View source
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Vhari Ingall · 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
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information.
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners . These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Source location Vhari Ingall · Prevention of Future Deaths report
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 to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate . In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information .
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Source location Vhari Ingall · Prevention of Future Deaths report
Open source report
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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 Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.
Verbatim wording from the response “We continue to respond to risk via routine monitoring and inspection during this consultation period, including concerns and issues raised in this report.” Source location 2020-0084-Response-from-CQC-to-further-PFD-report-Redacted
Open published response
20 Aug 2018 Jacob Sulaiman · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Inaccessibility of information about recent contacts with other services during emergency call-outs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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
London Borough of Camden
Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
View source
London Borough of Camden
Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
View source
London Borough of Camden
Develop information-sharing arrangements with London Ambulance Service.
View source
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AI-generated summary
Jacob Sulaiman · 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
Jacob Sulaiman died at home on 8 December 2017 after a fire started in his bedroom, causing carbon monoxide poisoning. The principal concerns were that response officers did not have complete or readily accessible information about his contacts with other services, including the outcome of a paramedic visit, which may have affected the assessment and management of his mental capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inaccessibility of information about recent contacts with other services during emergency call-outs
Wider context from the report “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
” Source location Jacob Sulaiman · Prevention of Future Deaths report
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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 Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
Verbatim wording from the response “In preparation for this move, a new IT platform was required to support the” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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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 Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
Verbatim wording from the response “This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Caroline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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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 information-sharing arrangements with London Ambulance Service.
Verbatim wording from the response “The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Caroline service has already made contact with LAS to begin discussions about how information could be better shared in future.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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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 Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
Verbatim wording from the response “Wellbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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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 Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
Verbatim wording from the response “It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Wellbeing were aware of, and coordinated the responses, whether they were remotely or in person.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
20 May 2015 Viola Burke · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Unavailability of computerised record access for the London Ambulance Service View source
This report raised 6 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.
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AI-generated summary
Viola Burke · 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
Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of computerised record access for the London Ambulance Service
Wider context from the report “(4) Evidence was given at inquest that the ‘Care Plan system’ was a Hackney wide initiative implemented in August 2014 by CHUHSE in collaboration with GP practices. The scheme was still in its infancy. The intention was to ensure that the London Ambulance Service and Out of Hours Services would have full access to the patient records of the most vulnerable upon agreement of the patient. Questions were also raised about how the care plan would be kept up to date, and whether the London Ambulance Service would have computerised access to records . Doctors attending Out of Hours operate in a medical vacuum, acting on findings in that moment without access to previous medical history, blood and blood pressure test results.
” Source location Viola Burke · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.