Recurring concern

Delays in ambulance attendance

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First reported 24 Feb 2014•Latest report 23 Mar 2026

Definition

What this concern includes

Includes recurring failures, resource constraints, dispatch problems and other dedicated ambulance-service response failures that result in delayed attendance to patients or emergency calls.

Not included

Excludes delays occurring after ambulance arrival, including hospital handover and crew-release delays.
Excludes delays in other emergency services, such as police, fire and rescue, or specialist clinical on-call attendance.
Excludes generic staffing, capacity or information-sharing deficiencies unless the reports explicitly tie them to delayed ambulance attendance.

Reports: 118
Individual concerns: 129
Date range: 2014–2026
Stated actions: 460

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 Care53

NHS England25

Welsh Ambulance Services NHS Trust22

Betsi Cadwaladr University LHB9

North East Ambulance Service NHS Foundation Trust8

Association of Ambulance Chief Executives7

East of England Ambulance Service NHS Trust7

East Midlands Ambulance Service NHS Trust6

Welsh Government6

Conwy County Borough Council4

Denbighshire County Council4

Flintshire County Council4

Gwynedd Council4

Isle of Anglesey County Council4

NHS West Yorkshire Integrated Care Board4

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 May2016
Manchester South
Concerns raised1
1. Delays in ambulance response to coded emergency calls
This report raised 3 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
  Explore ways to minimise lengthy ambulance waits during high-demand periods.
  Stated by North West Ambulance Service NHS TrustStated in progress
2. Action
  Secure funding for 400 additional frontline staff and 60 new vehicles.
  Stated by North West Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  Green 2 requires attendance as soon as practicable, not necessarily within 20 minutes; the delay reflected exceptional activity and hospital turnaround pressures.
  Stated by North West Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Christopher Philip Fields · 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

Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.

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
Delays in ambulance response to coded emergency calls
Wider context from the report
“2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes. Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS) ”
Source location
Christopher Philip Fields · Prevention of Future Deaths report
Page 1 · 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
Explore ways to minimise lengthy ambulance waits during high-demand periods.

Verbatim wording from the response
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.”

Source location
2016-0194-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 18 May 2016
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
Secure funding for 400 additional frontline staff and 60 new vehicles.

Verbatim wording from the response
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.”

Source location
2016-0194-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 18 May 2016
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
Green 2 requires attendance as soon as practicable, not necessarily within 20 minutes; the delay reflected exceptional activity and hospital turnaround pressures.

Verbatim wording from the response
“Taking each point in turn, I confirm that the vehicle response time for the incident in question, was inextricably linked to the activity pressures, NWAS faced during this extremely challenging winter period. Despite winter weather contingency planning, activity within the Greater Manchester area saw an unexpected 22% increase, which was directly compounded by significant hospital turnaround pressures faced at Stepping Hill, North Manchester and Oldham.”

Source location
2016-0194-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 18 May 2016
Open published response
11 May2016
Nottinghamshire
Concerns raised1
1. Insufficient availability of ambulance resources for urgent emergencies
This report raised 3 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

Mia 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

Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.

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
Insufficient availability of ambulance resources for urgent emergencies
Wider context from the report
“5. It is clear that resources played a part in these tragic events. No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that. The time between the 999 call and ████████ being handed over to maternity staff was an hour and 15 minutes. It was clear from the outset that ████████ would require urgent transfer to hospital – a mere 4 miles from her home address – but no resource was available. The evidence of those ‘on the ground’ clearly showed that this is far from an isolated incident, and I remain concerned that there is a risk of future deaths if this is not addressed. ”
Source location
Mia Gibson · Prevention of Future Deaths report
Page 3 · concerns
Open source report
20 Apr2016
South Wales Central
Concerns raised1
1. Failure to provide timely ambulance responses to Amber 2 calls
This report raised 3 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 1
1. Action
  Develop an action plan addressing the Regulation 28 improvement requirements.
  Stated by Welsh Ambulance Services NHS TrustStated completed
AI-generated summary

Ronald Hamer · 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

Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.

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 provide timely ambulance responses to Amber 2 calls
Wider context from the report
“1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes. It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again. ”
Source location
Ronald Hamer · Prevention of Future Deaths report
Page 1 · 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
Develop an action plan addressing the Regulation 28 improvement requirements.

Verbatim wording from the response
“I am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased). I would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the key actions for improvement. Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”

Source location
2016-0149-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 20 April 2016
Open published response
18 Apr2016
West Yorkshire (Western)
Concerns raised1
1. Delays in ambulance and doctor arrival for emergency treatment
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.

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

Carl Lee Thompson · 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

Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.

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
Delays in ambulance and doctor arrival for emergency treatment
Wider context from the report
“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”
Source location
Carl Lee Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Mar2016
Teesside
Concerns raised1
1. Ambulance shortages amid severe demand
This report raised 1 other concern. 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 29
1. Action
  Educate the public about appropriate ambulance-service use through extensive advertising and vehicle signage.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
2. Action
  Review the appropriateness of Red calls to reduce avoidable demand.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
3. Action
  Work with GPs and other health colleagues to reduce requests for ambulance transfers.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
1. Action
  Work with police to reduce ambulance requests made by police.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
2. Action
  Run a six-month trial dispatching Emergency Medical Responders alongside ambulances for life-threatening community emergencies.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
3. Action
  Introduce tri-responders working across police, fire and ambulance services.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
4. Action
  Operate the Emergency Care Workforce Plan and Task and Finish Group to increase emergency workforce numbers and address paramedic attrition.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
5. Action
  Recruit student paramedics, emergency care assistants and qualified paramedics to increase emergency response capacity.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
6. Action
  Recruit an additional 40 student paramedics during 2016–2017.
  Stated by North East Ambulance Service NHS Foundation TrustStated planned
7. Action
  Transfer advanced technicians into frontline operational roles to relieve lead-clinician pressures.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
8. Action
  Operate a paramedic bank for recent leavers to provide additional qualified cover for vacant shifts.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
9. Action
  Provide updated training for former staff joining the paramedic bank.
  Stated by North East Ambulance Service NHS Foundation TrustStated planned
10. Action
  Recruit internationally qualified paramedics, including processing recruits from Poland for frontline roles.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
11. Action
  Increase the in-house graduate paramedic training programme from 24 to 48 places with two annual intakes.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
12. Action
  Arrange for Sunderland University to train paramedics on demand rather than only according to the academic year.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
13. Action
  Deploy Emergency Care Clinical Managers to spend half their time on frontline work and cover operational shifts.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
14. Action
  Integrate Patient Transport Service staff into the workforce system and allocate work matching their skills.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
15. Action
  Develop an arrangement for volunteers to respond to Red 1 calls during meal breaks.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
16. Action
  Change the Patient Transport Service meal-break policy to permit breaks away from base stations and improve resource availability.
  Stated by North East Ambulance Service NHS Foundation TrustStated planned
17. Action
  Implement an overtime policy increasing paramedic availability across shifts.
  Stated by North East Ambulance Service NHS Foundation TrustStated planned
18. Action
  Increase recruitment, human-resources and training staffing capacity to fill frontline vacancies more quickly.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
19. Action
  Operate the interim Operational Recovery Action Plan using short-term measures and third-party providers to increase daily operational resources.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
20. Action
  Use framework third-party crews, vehicles and equipment to cover vacant shifts and resource shortfalls.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
21. Action
  Implement winter care projects and engage alternative care pathways to manage suitable patients outside hospital.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
22. Action
  Review agency and partnership arrangements to identify improvements.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
23. Action
  Deploy Hospital Ambulance Liaison Officers and Emergency Care Clinical Managers to improve hospital handover and ambulance turnaround.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
24. Action
  Use Ambulance Resource Assistants to restock equipment and position vehicles so crews return to incidents sooner.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
25. Action
  Continue using Advanced Paramedic Practitioners to assess and treat suitable patients at home, reducing unnecessary emergency transfers.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
26. Action
  Continue workforce recruitment strategies beyond ordinary workforce planning to increase emergency-care resources.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Control over calls and demand is limited, although demand-reduction initiatives are undertaken.
  Stated by North East Ambulance Service NHS Foundation TrustUnable to act
AI-generated summary

Mandeep SINGH · 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

Mandeep SINGH consumed high levels of alcohol and was found unconscious at home at approximately midnight after his wife found him lying on the floor. Although the ambulance call was assessed as R1 with a target response time of 8 minutes, the ambulance arrived after 27 minutes, and Mr Singh died in the ambulance. The investigation identified severe demand and staff shortages, as well as road closures and diversions, as factors in the delay.

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
Ambulance shortages amid severe demand
Wider context from the report
“A root cause analysis comprehensive and independent investigation report undertaken by the North East Ambulance Service discloses that the reasons for the delay of the ambulance arrival include severe demand and shortages in the division. Road closures and diversions did not assist the crews. ”
Source location
Mandeep SINGH · Prevention of Future Deaths report
Page 1 · 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
Educate the public about appropriate ambulance-service use through extensive advertising and vehicle signage.

Verbatim wording from the response
“The Trust is limited in ways in which it can control the calls made to it and the demand on its services. However, the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 1 · response
Published 23 March 2016
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 the appropriateness of Red calls to reduce avoidable demand.

Verbatim wording from the response
“The Trust has also carried out demand reduction work looking at how to reduce the number of red calls made by looking at the appropriateness of those red calls.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 2 · response
Published 23 March 2016
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
Work with GPs and other health colleagues to reduce requests for ambulance transfers.

Verbatim wording from the response
“The Trust has worked with colleagues in relation to demand reduction. The Trust has worked with health colleagues for example GP’s, to ascertain whether requests for ambulance transfers can be reduced.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 2 · response
Published 23 March 2016
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
Work with police to reduce ambulance requests made by police.

Verbatim wording from the response
“The Trust has also worked with the police to see if any reduction in ambulances requested by the police can be effected.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 2 · response
Published 23 March 2016
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
Run a six-month trial dispatching Emergency Medical Responders alongside ambulances for life-threatening community emergencies.

Verbatim wording from the response
“In January 2016, the Trust commenced a new six-month trial scheme with the four Fire and Rescue Services based in the region. This includes Cleveland Fire Brigade, County Durham and Darlington Fire and Rescue Service, Northumberland Fire and Rescue Service and Tyne and Wear Fire and Rescue Service.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 2 · response
Published 23 March 2016
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
Introduce tri-responders working across police, fire and ambulance services.

Verbatim wording from the response
“Finally the Trust has worked in partnership with Durham Constabulary and County Durham and Darlington Fire and Rescue Service to introduce the region’s first tri-responders working for police, fire and ambulance. The Community First Responders work for Durham Constabulary as PCSOs, County Durham and Darlington Fire and Rescue Service as retained firefighters and as first responders for the NEAS.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 2 · response
Published 23 March 2016
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
Operate the Emergency Care Workforce Plan and Task and Finish Group to increase emergency workforce numbers and address paramedic attrition.

Verbatim wording from the response
“In order to seek to address this shortfall, the Trust has been following an Emergency Care Workforce Plan. This Workforce Plan has always existed however, given the increase in attrition of staff, a Task and Finish Group was established in October 2014, in order to ensure that the Trust is employing as many strategies as possible to increase emergency workforce numbers. This includes a two-year programme designed to increase the number of paramedics employed by the Trust and involves various initiatives which are aimed at tackling the problem of paramedic attrition. We will explain in greater detail below the specific steps which the Trust is taking pursuant to the Workforce Plan to address resource and recruitment issues. It was previously hoped that the process to address the current shortfall in paramedics would be fully addressed by September 2016.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 4 · response
Published 23 March 2016
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
Recruit student paramedics, emergency care assistants and qualified paramedics to increase emergency response capacity.

Verbatim wording from the response
“The Trust has been actively working to recruit more paramedics into the service in order to increase the resources it has available to respond to the higher volume of emergency calls which it is required to deal with in the present climate. The Trust has always had a workforce plan in place however new strategies have since been introduced after the Trust discovered in/around mid-2014 that more paramedics were leaving their employment than the numbers being recruited to fill vacancies.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Recruit an additional 40 student paramedics during 2016–2017.

Verbatim wording from the response
“At this stage, the Trust has recruited 104 student paramedics and 204 emergency care assistants since January 2014. In addition the Trust has planned to recruit an additional 40 student paramedics during 2016/2017. The Trust has also recruited 31.5 qualified paramedics and will continue to recruit in this role with a healthy pipeline. The emergency care assistants and technicians will support paramedics in attending emergency calls, including driving the ambulance and assisting with medical intervention, having been trained in basic life support.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Transfer advanced technicians into frontline operational roles to relieve lead-clinician pressures.

Verbatim wording from the response
“At the same time, the Trust has been transferring advanced technicians to frontline operational roles in order to reduce frontline pressures for lead clinicians. 20 members of staff have so far agreed to this. Advanced technicians, like paramedics, are trained to deal with life threatening illnesses and injuries. They are therefore very experienced members of staff. However, paramedics are also trained to undertake invasive procedures which may need to be performed during the most serious medical emergencies, including intubation (where a tube is inserted into the windpipe to help a patient breathe) and cannulation (where a thin tube is inserted into a vein in order to introduce fluid and drugs as quickly as possible).”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Operate a paramedic bank for recent leavers to provide additional qualified cover for vacant shifts.

Verbatim wording from the response
“The Trust has also implemented a paramedic bank for recent leavers, whereby qualified paramedics who leave the Trust's employment, are asked whether they are interested in joining the Trust's paramedic bank. This is designed to increase the number of qualified paramedics available to fill vacant shifts. The Trust proceeded to complete recruitment checks on these individuals and will provide updated training for ex-members of staff who join the paramedic bank. It was initially anticipated that these individuals would be available to undertake frontline clinical duties from around May 2015. Given the recruitment pressures which the Trust has faced, this was pushed back slightly, however the paramedic bank has been in place since around October/November 2015, therefore allowing cover for the winter pressure period.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide updated training for former staff joining the paramedic bank.

Verbatim wording from the response
“The Trust has also implemented a paramedic bank for recent leavers, whereby qualified paramedics who leave the Trust's employment, are asked whether they are interested in joining the Trust's paramedic bank. This is designed to increase the number of qualified paramedics available to fill vacant shifts. The Trust proceeded to complete recruitment checks on these individuals and will provide updated training for ex-members of staff who join the paramedic bank. It was initially anticipated that these individuals would be available to undertake frontline clinical duties from around May 2015. Given the recruitment pressures which the Trust has faced, this was pushed back slightly, however the paramedic bank has been in place since around October/November 2015, therefore allowing cover for the winter pressure period.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Recruit internationally qualified paramedics, including processing recruits from Poland for frontline roles.

Verbatim wording from the response
“Moreover, the Trust had also placed an advert for qualified paramedics in the periodical "Ambulance Life" which has an international reach and has been pursuing other international recruitment campaigns. This has resulted in the recruitment of 19 paramedics from Poland, with 4 individuals ready to commence front-line clinical roles and the remaining 15 currently being processed.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Increase the in-house graduate paramedic training programme from 24 to 48 places with two annual intakes.

Verbatim wording from the response
“As noted above, one major issue faced by Ambulance Trusts nationally with respect to recruitment is the fact that all would-be paramedics have to undertake a 2 year training course at University, which effectively means that the Trust has to recruit 2 years in advance of employment commencement. As such, and in order to attempt to tackle the resource shortfall, the Trust has increased the number of places on its 2 year in-house graduate training programme from the usual 24 places to 48 places, with a two-stage intake in February and April. This results in the Trust having a year-end forecast number of student paramedics of approximately 100. The Trust have also visited universities in an attempt to recruit paramedics who are pursuing their studies but are not yet licensed to a particular ambulance service upon qualification.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Arrange for Sunderland University to train paramedics on demand rather than only according to the academic year.

Verbatim wording from the response
“An arrangement has also been negotiated with Sunderland University whereby they will train paramedics as and when requested by the Trust and not just in line with the academic year in order to help match our demand.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 5 · response
Published 23 March 2016
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
Deploy Emergency Care Clinical Managers to spend half their time on frontline work and cover operational shifts.

Verbatim wording from the response
“The Trust has also recruited a total of 56 Emergency Care Clinical Managers (ECCMs) who have been recruited from the current team leader pool. ECCMs manage the Trust's ambulance stations and ordinarily spend 90% of their time undertaking management/supervisory/governance work, with the remaining 10% on the front line. However, in order to help ease frontline pressures in the current climate, the ECCMs will spend 50% of their time working on the front line and will be able to cover a number of shifts.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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
Integrate Patient Transport Service staff into the workforce system and allocate work matching their skills.

Verbatim wording from the response
“In addition, the Trust has been looking to increase the number of PTS (Patient Transport Service) staff. A PTS member of staff transports patients to and from planned appointments at a range of healthcare providers. Our PTS staff are now fully integrated into the Trust's workforce system and are allocated jobs appropriate to their skill base. This should help free up the Trust's more experienced and qualified paramedics to deal with the most urgent emergency calls.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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 an arrangement for volunteers to respond to Red 1 calls during meal breaks.

Verbatim wording from the response
“The question as to whether staff should be available to respond to calls during their statutory meal break has been debated extensively by the Association of Ambulance Chief Executives and with the Secretary of State for Health. We have held detailed discussions with other ambulance services about this issue also. The Trust have now proposed to the paramedic Unions that crews should be asked whether they will agree to cease their meal break in order to attend life threatening Red 1 (8 minute emergency response) calls. This proposal was initially rejected by the Unions. However, we have continued to seek the Unions' engagement on this issue and both Unison and GMB have since both agreed in principle for their members to be asked to volunteer to respond to R1 calls while they are on their break.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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
Change the Patient Transport Service meal-break policy to permit breaks away from base stations and improve resource availability.

Verbatim wording from the response
“In addition, there was to be a change to the meal break policy across the Trust PTS team in order to enable staff to be able to take their meal breaks at locations away from their base stations and at other sites. Pursuant to the previous meal break policy, staff returned to their own base stations in order to have their compulsory meal break and were effectively unable to respond to any incoming calls during this period. The aim was therefore to reduce travelling time going to/from base stations and to improve resource allocation and utilisation of staff time by reducing travelling. Such changes were also intended to reduce vehicle usage, with less fuel and vehicle maintenance being required, therefore allowing the Trust to keep more vehicles on the road to attend emergency calls.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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
Implement an overtime policy increasing paramedic availability across shifts.

Verbatim wording from the response
“On a separate note, the Trust has been planning for some time to implement a new overtime policy which would see an increased number of paramedic resources being available across all shifts. This has taken a while to implement as a consequence of extensive negotiations with the Unions however the Trust anticipate such a policy being introduced very shortly.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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
Increase recruitment, human-resources and training staffing capacity to fill frontline vacancies more quickly.

Verbatim wording from the response
“In addition to those measures set out above, in the long term, the Trust has been looking to increase its own recruitment capacity, by employing more staff in recruitment, human resources and training roles. This will enable new staff to be recruited and trained in a timely manner in order to fill frontline vacancies. This remains the case.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 6 · response
Published 23 March 2016
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
Operate the interim Operational Recovery Action Plan using short-term measures and third-party providers to increase daily operational resources.

Verbatim wording from the response
“The Trust have also implemented an interim Operational Recovery Action Plan, which focuses on short term solutions to deal with operational resource availability and is expected to increase the Trust's resources on a day to day basis by utilising third party providers to fill current vacancies. A number of initiatives have also been implemented to improve response times to low priority calls (i.e. calls which are not categorised as a red '8 minute' emergency response).”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 7 · response
Published 23 March 2016
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
Use framework third-party crews, vehicles and equipment to cover vacant shifts and resource shortfalls.

Verbatim wording from the response
“Third party agencies on the Trust's local framework continue to be utilised on a daily basis in order to provide support and to assist with responding to G2 (30 minute) and low priority emergency and GP urgent calls, which are within their capability. Third party providers on the framework are trained to an equivalent level as a Trust Ambulance Technician or a Trust PTS Assistant. The Trust is still currently seeking qualified paramedics from third party providers as a further short term solution to increasing higher skilled operational roles whilst recruitment continues pursuant to the above mentioned Workforce Plan. Using the Trust's local third party framework, an agreement has been reached where our third party partners can be drawn upon to cover short falls in emergency and urgent care resources, where necessary.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 7 · response
Published 23 March 2016
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
Implement winter care projects and engage alternative care pathways to manage suitable patients outside hospital.

Verbatim wording from the response
“Furthermore, the Trust has been working closely with the local Clinical Commissioning Groups to sustain and improve the provision of patient care over the winter periods through specific winter projects. A winter care plan was in place to help alleviate the additional seasonal pressures. The Trust has also undertaken a review of its agency and partnership arrangements in order to determine if current arrangements can be improved. These measures are aimed at maximising patient care within the home environment, where appropriate, in order to avoid unnecessary Accident and Emergency Department attendances. This is designed to increase Trust emergency ambulance resource availability. The Trust also continues to engage with other providers/pathways in order to manage patients outside of hospital, where appropriate.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 7 · response
Published 23 March 2016
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 agency and partnership arrangements to identify improvements.

Verbatim wording from the response
“Furthermore, the Trust has been working closely with the local Clinical Commissioning Groups to sustain and improve the provision of patient care over the winter periods through specific winter projects. A winter care plan was in place to help alleviate the additional seasonal pressures. The Trust has also undertaken a review of its agency and partnership arrangements in order to determine if current arrangements can be improved. These measures are aimed at maximising patient care within the home environment, where appropriate, in order to avoid unnecessary Accident and Emergency Department attendances. This is designed to increase Trust emergency ambulance resource availability. The Trust also continues to engage with other providers/pathways in order to manage patients outside of hospital, where appropriate.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 7 · response
Published 23 March 2016
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
Deploy Hospital Ambulance Liaison Officers and Emergency Care Clinical Managers to improve hospital handover and ambulance turnaround.

Verbatim wording from the response
“The Trust once again deployed Hospital Ambulance Liaison Officers (HALOs) across the region during the winter period, in order to assist both hospitals and ambulance crews during times of pressure. The HALOs ceased their role in March 2016. This responsibility has now been taken up by the ECCMs who undertake this role throughout the rest of the year.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 8 · response
Published 23 March 2016
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
Use Ambulance Resource Assistants to restock equipment and position vehicles so crews return to incidents sooner.

Verbatim wording from the response
“Similarly, the Trust has sought to make use of dedicated Ambulance Resource Assistants (ARAs) over the recent winter periods, who play a key role in supporting the utilisation of our front line emergency and PTS crews by ensuring equipment and consumables are restocked at hospitals and operational stations, thereby reducing the need for crews to travel back to core sites to restock, losing valuable operational time which could be spent responding to incidents. The ARAs also ensure that vehicles are transported to the appropriate locations for the commencement of shifts, thereby maximising the utilisation time amongst crews responding to incidents.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 8 · response
Published 23 March 2016
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
Continue using Advanced Paramedic Practitioners to assess and treat suitable patients at home, reducing unnecessary emergency transfers.

Verbatim wording from the response
“Finally, the Trust are also continuing to utilise Advanced Paramedic Practitioners (APPs). These clinicians have proven advanced patient assessment skills of the same level as Emergency Care Practitioners and are able to assess, treat and in most cases, ensure that the patient is safely treated at home, where appropriate. As a result, suitable patients are assessed and treated by APPs in their own home if this is more appropriate than a transfer to hospital. This forms part of the Trust's focus on improving patient care and experience, as well as to reduce the demand on front line emergency crews by recognising the importance of ensuring that only those patients who are in need of a hospital admission in an emergency situation receive an emergency ambulance disposition.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 8 · response
Published 23 March 2016
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
Continue workforce recruitment strategies beyond ordinary workforce planning to increase emergency-care resources.

Verbatim wording from the response
“In light of the above issues, all ambulance services across the country, including the Trust, are pursuing various workforce recruitment strategies in an attempt to increase their emergency care resource base. Over the last 12 months, the Trust has improved its paramedic resource base and attrition rates have improved, whereby there are now more paramedics commencing roles at the Trust than the number of staff leaving employment. At this stage, the Trust has a skill vacancy of around 20% which has reduced from 25%. The Trust's attrition rate has therefore improved in comparison to other ambulance services across the country. However, there still remains a shortfall of people entering the paramedic profession nationally. As such, the Trust will continue with its workforce recruitment strategies which go beyond ordinary workforce planning.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 9 · response
Published 23 March 2016
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
Control over calls and demand is limited, although demand-reduction initiatives are undertaken.

Verbatim wording from the response
“The Trust is limited in ways in which it can control the calls made to it and the demand on its services. However, the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.”

Source location
2016-0116-Response-by-North-East-Ambulance-Service
Page 1 · response
Published 23 March 2016
Open published response
12 Nov2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Delays in ambulance attendance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide additional education and support to all call takers involved in the incident.
  Stated by Welsh Ambulance Services NHS TrustStated completed
Respondent positions 1
1. Position
  The ambulance was allocated one minute before South Wales Police contacted the control centre, rather than after police expedited the call.
  Stated by Welsh Ambulance Services NHS TrustDisputes the concern
AI-generated summary

Christopher George Connor · 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

Christopher George Connor had been socialising at a public house before leaving in the early hours and being found collapsed and unresponsive on a pavement near his home. An ambulance took over 1 hour and 15 minutes to arrive, and the principal concern was the delay in ambulance attendance.

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
Delays in ambulance attendance
Wider context from the report
“(1) The delay in the attendance of an ambulance which, on the evidence, only arrived after police officers arrived on the scene and “expedited” the call to the ambulance control room. ”
Source location
Christopher George Connor · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide additional education and support to all call takers involved in the incident.

Verbatim wording from the response
“The investigation determined that the root cause of the failings emanated from one individual member of staff. Specifically the Clinical Contact Centre Allocator and I can confirm that the Trust has acted upon these findings in relation to that individual who is currently being managed in line with the Trust’s relevant policies and procedures regarding the failings identified. I can assure you that the Trust views matters of this nature extremely seriously and in addition to the above, all the call takers involved in this incident have also received additional education and support.”

Source location
2016-0461-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 November 2015
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 ambulance was allocated one minute before South Wales Police contacted the control centre, rather than after police expedited the call.

Verbatim wording from the response
“One minute after allocation of this vehicle, a third call was received in relation to this incident from South Wales Police informing our Clinical Contact Centre that they had received a call for this patient. The Trust call taker who had remained in contact with the caller identified that a police officer arrived at the scene at approximately 02:00hrs.”

Source location
2016-0461-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 November 2015
Open published response
28 Oct2015
Manchester West
Concerns raised1
1. Failure to immediately establish responsibility for calling an ambulance
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

Christopher John Smith · 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

Christopher John Smith died instantaneously after jumping from Barton Bridge on 15 July 2015. The principal concern was a 12-minute delay in contacting the ambulance service, caused by a communication breakdown about which service was responsible for making the call, although this did not affect the outcome in this case.

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 immediately establish responsibility for calling an ambulance
Wider context from the report
“1) It was clear from the evidence that there was a 12 minute delay in the police contacting the ambulance – the police were notified of the incident but did not contact North West Ambulance Service immediately. 2) In the circumstances of this Inquest I was satisfied that this delay had not had any relevance with regards to Christopher Smith’s death, given that the pathologist had concluded that his death was instantaneous. Any delay in the ambulance arriving was therefore not going to save his life. 3) However, it is perfectly possible to foresee circumstances where a delay in calling for an ambulance may have an effect on the outcome, where someone has jumped or fallen from a lesser distance. 4) I was told that the 12 minute delay was due to a breakdown in communication between Greater Manchester Police control room and the Motorway Control – Greater Manchester Police thought that the Motorway Control were contacting the ambulance and vice versa. 5) It seems to me that procedure should be in place whereby it is immediately established who is going to be responsible for calling the ambulance to avoid any delays, and the ambulance is called for at once. ”
Source location
Christopher John Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Sep2015
Central Lincolnshire
Concerns raised1
1. Delays in dispatching ambulances to patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Increase frontline and emergency operations centre staffing, including flexible relief capacity for predicted demand.
  Stated by East Midlands Ambulance Service NHS TrustStated completed
2. Action
  Increase the available vehicle fleet to deploy more ambulance resources concurrently.
  Stated by East Midlands Ambulance Service NHS TrustStated completed
3. Action
  Introduce Paramedic Pathfinder and train frontline staff to use it for pre-hospital assessment and appropriate referral.
  Stated by East Midlands Ambulance Service NHS TrustStatus at response
1. Action
  Develop specialist pathfinder tools and referral services for specific conditions through CQUIN-funded project work.
  Stated by East Midlands Ambulance Service NHS TrustStated planned
2. Action
  Expand the Clinical Assessment Team to provide continuous clinician-led telephone assessment and hear-and-treat support.
  Stated by East Midlands Ambulance Service NHS TrustStated completed
3. Action
  Operate a dynamically deployable single Ambulance Technician vehicle in Skegness and Boston for suitable calls, supported by Clinical Assessment Team referrals or discharge.
  Stated by East Midlands Ambulance Service NHS TrustStated completed
AI-generated summary

Stuart Knight · 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

Stuart Knight was found unconscious in a road in Wainfleet after apparently falling backwards and hitting his head. There were delays in the arrival of ambulance services, including 1 hour and 24 minutes between the first call and the arrival of the double-crewed ambulance; the report identified these delays as significant and unacceptable. Mr Knight was taken to hospital and died later that day, following a head injury with haemorrhage and skull fracture, with alcohol excess also recorded as a medical cause.

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
Delays in dispatching ambulances to patients
Wider context from the report
“(I) Significant and unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury. Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS. ”
Source location
Stuart Knight · 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
Increase frontline and emergency operations centre staffing, including flexible relief capacity for predicted demand.

Verbatim wording from the response
“East Midlands Ambulance Service has made significant investment in both staff and vehicle resources since 2014 in both “frontline” staff who attend 999 calls but also in staffing within the emergency operations centre.”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 2 · response
Published 22 September 2015
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
Increase the available vehicle fleet to deploy more ambulance resources concurrently.

Verbatim wording from the response
“In addition we have invested in our fleet provision to increase the number of vehicles we have available allowing the trust to deploy more resources at any one time.”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 2 · response
Published 22 September 2015
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
Introduce Paramedic Pathfinder and train frontline staff to use it for pre-hospital assessment and appropriate referral.

Verbatim wording from the response
“We have supported our frontline staff with the introduction of Paramedic Pathfinder (PP). PP is a pre hospital assessment guide based around the widely used NEWS (National early warning system) designed to assist crews to identify patients that are suitable for onward referral as opposed to transport to the emergency department. Typically when a patient is not conveyed from their home address (See and Treat), the job cycle time (total time the ambulance is dealing with that particular call and is therefore unavailable) is reduced. Starting in April 2014, by October 2015 94% of staff have completed the training.”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 2 · response
Published 22 September 2015
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 specialist pathfinder tools and referral services for specific conditions through CQUIN-funded project work.

Verbatim wording from the response
“For the longer term this translates into a project based on Commissioning for Quality and Innovation (CQUIN) money to develop specialist pathfinder tools for specific conditions ultimately to identify and”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 2 · response
Published 22 September 2015
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
Expand the Clinical Assessment Team to provide continuous clinician-led telephone assessment and hear-and-treat support.

Verbatim wording from the response
“We have invested significantly in the scope of our Clinical Assessment Team (CAT) based in the emergency operations centre. The CAT team are a group of clinicians, qualified Paramedics and Nurses, who work within the EOC on a 24 hour a day 7 day per week rota. They work providing support and telephone assessment to 999 calls received by the trust. The result of the telephone assessment can, in some serious cases, ensure that a call is dealt with as a higher priority due to clinical need or, in other cases, result in the call being dealt with to a conclusion by the CAT clinician. This is termed as “hear and treat”. In dealing with calls in this manner this ensures that frontline resources are not sent if not required therefore making them available to mobilise to patients with more serious clinical need that require immediate treatment or transport.”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 3 · response
Published 22 September 2015
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
Operate a dynamically deployable single Ambulance Technician vehicle in Skegness and Boston for suitable calls, supported by Clinical Assessment Team referrals or discharge.

Verbatim wording from the response
“As a local initiative between the Trust and the commissioning group in east Lincolnshire, a single Ambulance Technician vehicle is available to be deployed dynamically to calls where a traditional double crewed ambulance may not be required, for example a non-injury fall requiring assistance. Supported by the CAT team this resource can suitable respond to a call and through CAT refer or discharge at scene, again negating the need for an ambulance to be deployed. The scheme covers both the Skegness and Boston areas and has run from April 2015 with the following attendances. On average this initiative allows around 40 calls per month to be appropriately and safely assisted, referred and discharged without the need for the attendance of an emergency ambulance.”

Source location
2015-0385-Response-by-East-Midlands-Ambulance-Service
Page 3 · response
Published 22 September 2015
Open published response
7 Aug2015
Leicester City and South Leicestershire
Concerns raised1
1. Failure to escalate stroke-patient collection requests to a medical emergency response
This report raised 3 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 3
1. Action
  Discuss the additional workforce changes required with lead commissioners to support AMPDS triage for urgent GP and healthcare-professional calls.
  Stated by East Midlands Ambulance Service NHS TrustStated planned
2. Action
  Communicate emergency-response guidance to lead commissioners for dissemination to GPs and Bed Bureau services.
  Stated by East Midlands Ambulance Service NHS TrustStated planned
3. Action
  Undertake a clinical review of ambulance response protocols and develop recommendations for changes to national ambulance service standards.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  Implementing AMPDS triage for all GP and healthcare-professional urgent calls requires additional paramedics; implementation cannot proceed without increased staffing.
  Stated by East Midlands Ambulance Service NHS TrustUnable to act
AI-generated summary

George Boulton · 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

George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

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 escalate stroke-patient collection requests to a medical emergency response
Wider context from the report
“3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time, rather than the actual allocated 2 hour response time. ”
Source location
George Boulton · 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
Discuss the additional workforce changes required with lead commissioners to support AMPDS triage for urgent GP and healthcare-professional calls.

Verbatim wording from the response
“In order for EMAS to migrate over to this protocol and using a medical triage system (AMPDS) for all GP urgent and Bed Bureau calls, we will need to uplift the response capability across the region by additional Paramedics.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 2015
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
Communicate emergency-response guidance to lead commissioners for dissemination to GPs and Bed Bureau services.

Verbatim wording from the response
“As this implementation will take some considerable amount of time, as an immediate action we will communicate with our lead commissioners to disseminate the following message to all GP’s and Bed Bureau.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 2015
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
Undertake a clinical review of ambulance response protocols and develop recommendations for changes to national ambulance service standards.

Verbatim wording from the response
“3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time, rather than the actual allocated 2 hour response time.”

Source location
2015-0255-Responses
Page 7 · response
Published 6 July 2015
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
Implementing AMPDS triage for all GP and healthcare-professional urgent calls requires additional paramedics; implementation cannot proceed without increased staffing.

Verbatim wording from the response
“Prior to this Prevention of Future deaths (PFD) order being received our senior managers and business intelligence teams have explored the possibility of implementing the AMPDS system to triage all GP and Health Care Professionals (HCP) requests for urgent transport.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 2015
Open published response
21 May2015
Northumberland (North)
Concerns raised1
1. Delays in ambulance arrival beyond the target response time
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
  Stated by Care Quality CommissionStated planned
2. Action
  Require NEAS to provide evidence on ambulance arrival-time breaches and measures to mitigate or reduce missed targets.
  Stated by Care Quality CommissionStated completed
Respondent positions 1
1. Position
  The eight-minute ambulance response target does not require every life-threatening call to receive a response within eight minutes.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Barbara Patterson · 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

Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.

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
Delays in ambulance arrival beyond the target response time
Wider context from the report
“4. The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes. ”
Source location
Barbara Patterson · Prevention of Future Deaths report
Page 1 · 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
Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.

Verbatim wording from the response
“The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence to demonstrate that they understand their role and responsibilities in relation to call handlers and that they provide regular monitoring to ensure that the system is functioning at an appropriate level.”

Source location
2015-0198-Response-by-Care-Quality-Commission
Page 2 · response
Published 21 May 2015
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
Require NEAS to provide evidence on ambulance arrival-time breaches and measures to mitigate or reduce missed targets.

Verbatim wording from the response
“of ambulances is appropriate and what, if any, improvements can be made to the current system. We have written to NEAS to instruct them to submit evidence of their current position around breaches of arrival times of their ambulances together with providing evidence of how they are mitigating the risk of or reducing the missed target times of ambulance arrivals.”

Source location
2015-0198-Response-by-Care-Quality-Commission
Page 3 · response
Published 21 May 2015
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 eight-minute ambulance response target does not require every life-threatening call to receive a response within eight minutes.

Verbatim wording from the response
“The target for an emergency ambulance response is that 75% of all Red 1 calls – the most serious, life-threatening category – receive a response within eight minutes. While ambulance services will always attempt to provide a response as soon as possible in life-threatening situations, the target recognises that it is unfortunately not always physically possible for ambulance services to respond to all Red 1 calls within eight minutes.”

Source location
2015-0198-Response-by-Department-of-Health
Page 2 · response
Published 21 May 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in ambulance response to coded emergency calls

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

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

Concerns raised1

Insufficient availability of ambulance resources for urgent emergencies

Concerns raised1

Failure to provide timely ambulance responses to Amber 2 calls

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.1

Concerns raised1

Delays in ambulance and doctor arrival for emergency treatment

Concerns raised1

Ambulance shortages amid severe demand

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.29

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

Actions described in response 2

Respondent positions 1

Actions described in response 1

Actions described in response 29

Respondent positions 1