Concerns raised 1
Delays in ambulance response 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
Margaret Megan Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.
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× 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
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Source location Margaret Megan Evans · Prevention of Future Deaths report
Open source report
25 Jun 2018 Marjorie McMahon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance and paramedic attendance for level 2 priority calls View source
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
Marjorie McMahon · 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
Marjorie McMahon became increasingly unwell at Cherry Tree House and was taken to hospital on 7 March 2018, where she received treatment before dying on 8 March 2018. The principal concern was the delay in ambulance and paramedic attendance despite her being categorised as a level 2 priority, with an 8-minute guideline response time.
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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 Delays in ambulance and paramedic attendance for level 2 priority calls
Wider context from the report “Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7th March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not attended to for nearly 1 ½ hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance). The guideline response time was confirmed to be 8 minutes.
” Source location Marjorie McMahon · Prevention of Future Deaths report
Open source report
27 Feb 2018 Raymond Henry Davidson (Raymond) · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Insufficient ambulance resources causing delays to urgent responses View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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. 13
North East Ambulance Service NHS Foundation Trust
Develop and approve an action plan with timescales for addressing the funding shortfall and delivering ambulance response standards.
View source
North East Ambulance Service NHS Foundation Trust
Achieve a 25% frontline-staff abstraction target through a 33.3% relief rate and associated workforce efficiency.
View source
North East Ambulance Service NHS Foundation Trust
Establish and operate an implementation group to develop, implement and oversee the detailed ORH implementation plan.
View source
North East Ambulance Service NHS Foundation Trust
Improve crew shift start and finish times to increase crew availability.
View source
North East Ambulance Service NHS Foundation Trust
Improve dispatch-team productivity by reducing the number of ambulances managed by each dispatcher.
View source
North East Ambulance Service NHS Foundation Trust
Audit dispatch allocation times monthly and provide training or action plans where dispatchers need support.
View source
North East Ambulance Service NHS Foundation Trust
Reduce C2 conveyance rates in Central and North divisions toward South division levels by 2021/22.
View source
North East Ambulance Service NHS Foundation Trust
Work with Northumberland CCG to establish a multidisciplinary rapid response team for lower-acuity community cases.
View source
North East Ambulance Service NHS Foundation Trust
Provide 50 additional E-Care course places to equip staff to leave suitable patients safely at home.
View source
North East Ambulance Service NHS Foundation Trust
Reduce hospital handover times toward a 30-minute mean in each division by 2018/19.
View source
North East Ambulance Service NHS Foundation Trust
Use a regional handover standard operating procedure and task-and-finish collaboration to improve accountability for ambulance handovers.
View source
North East Ambulance Service NHS Foundation Trust
Base an operational manager permanently within two acute trusts to monitor, manage and escalate handover issues.
View source
North East Ambulance Service NHS Foundation Trust
Implement the REAP and Escalation Policy defining actions for Emergency Operations Centre and operational staff in response to demand.
View source See 10 more actions
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AI-generated summary
Raymond Henry Davidson (Raymond) · 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
Raymond Henry Davidson died at home on 10 June 2017 after ambulance responses to urgent and emergency calls did not attend before he stopped breathing. The report identified ongoing ambulance resource shortages and delays in responding to urgent cases, as well as concerns that the initial clinical review was not sufficiently robust because telephone contact was not made directly with Raymond.
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× 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 ambulance resources causing delays to urgent responses
Wider context from the report “I heard evidence that: -
• the recruitment/retention of staff had improved; and
• welfare calls triggered earlier clinician involvement than previously; and
• although there were several other initiatives under way, operational shortages were ongoing .
Raymond’s death highlighted resource issues. There was only so much NEAS could do when they simply did not have enough ambulances to send . At times demand was greater than the resources NEAS had available . The effect of urgent cases being interposed put back those cases appearing to be less urgent . In this case: -
• 10 hours 51 minutes elapsed from the original 111 call;
• 8 hours and 29 minutes after the urgent categorisation; and
• 1 hour 3 minutes after the case was prioritised as a G2 response.
This is the third such report about the same issue that I have written in recent months as I consider that there is a risk of future deaths. An urgent review of resources and their application is needed.
Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly, which may have impacted on the less than robust initial clinical review of Raymond’s condition.
” Source location Raymond Henry Davidson (Raymond) · 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 Develop and approve an action plan with timescales for addressing the funding shortfall and delivering ambulance response standards.
Verbatim wording from the response “– We are aiming to develop and approve an action plan by the end of May 2018 that will include timescales to address the shortfall in funding and deliver the ARP standards;” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Achieve a 25% frontline-staff abstraction target through a 33.3% relief rate and associated workforce efficiency.
Verbatim wording from the response “– Within this agreement, an assumption is made in the ORH report that abstraction rates of frontline staff are reduced from 34.4%. A target abstraction level of 25%,” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Establish and operate an implementation group to develop, implement and oversee the detailed ORH implementation plan.
Verbatim wording from the response “The Trust has started to share the content of the ORH report with stakeholders via a number of engagement events. We have established an implementation group who will develop, implement and oversee a detailed implementation plan. This will include current rosters versus new, staffing implications, vehicles and estates. The Trust and partners are reviewing contractual implications alongside the approval processes.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Improve crew shift start and finish times to increase crew availability.
Verbatim wording from the response “We are working with ORH to look to improve our crew shift start and finish times. This will also assist with better overall availability of crews throughout the shift. We are also looking to improve the productivity of the dispatch teams by reducing the number of ambulances managed by each dispatcher.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Improve dispatch-team productivity by reducing the number of ambulances managed by each dispatcher.
Verbatim wording from the response “We are working with ORH to look to improve our crew shift start and finish times. This will also assist with better overall availability of crews throughout the shift. We are also looking to improve the productivity of the dispatch teams by reducing the number of ambulances managed by each dispatcher.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Audit dispatch allocation times monthly and provide training or action plans where dispatchers need support.
Verbatim wording from the response “The Dispatch managers monitor on a monthly basis through audit, the allocation times of the dispatch team. The time frames are monitored in line with national guidance to ensure compliance. Individual training and actions plans can and are issued with any dispatcher who needs further support in ensuring calls are allocated within the given dispatch standard times” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Reduce C2 conveyance rates in Central and North divisions toward South division levels by 2021/22.
Verbatim wording from the response “2. Some reduction in conveyance rates is also feasible, with a corresponding increase in time at scene, particularly in Central and North divisions.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Work with Northumberland CCG to establish a multidisciplinary rapid response team for lower-acuity community cases.
Verbatim wording from the response “We are working with Northumberland CCG to put in place a rapid response team who will provide a multidisciplinary team to respond to a wide range of lower acuity cases in the community to provide paramedics with an alternative option to ED. We have provided 50” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Provide 50 additional E-Care course places to equip staff to leave suitable patients safely at home.
Verbatim wording from the response “We are working with Northumberland CCG to put in place a rapid response team who will provide a multidisciplinary team to respond to a wide range of lower acuity cases in the community to provide paramedics with an alternative option to ED. We have provided 50” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Reduce hospital handover times toward a 30-minute mean in each division by 2018/19.
Verbatim wording from the response “3. A reduction in time at hospital should be targeted, particularly in Central and North divisions, aiming to reduce to a 30-minute mean by 2018/19 in each division.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Use a regional handover standard operating procedure and task-and-finish collaboration to improve accountability for ambulance handovers.
Verbatim wording from the response “We are working with our partners across the region in a Task and Finish Group to focus on ambulance handovers. We hold a weekly conference call with all of the acute trusts, NHS England, NHS Improvement and the North East Urgent and Emergency Care Network to address issues and formulate strategies to improve handover. We have developed a joint standard operating procedure for handover across the region which has been in place since November. We are working together to ensure that there is a culture of accountability for handover embedded in both the acute and ambulance Trusts at grass roots level. Hospital Handover is part of every individual’s objective and discussed during performance reviews and ride-outs.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Base an operational manager permanently within two acute trusts to monitor, manage and escalate handover issues.
Verbatim wording from the response “We are basing an Operational manager permanently within two acute trusts to monitor and manage the handover process and build relationships within the hospital to ensure that issues are escalated early so we can take proactive action before we start to experience handover delays” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Implement the REAP and Escalation Policy defining actions for Emergency Operations Centre and operational staff in response to demand.
Verbatim wording from the response “The Trust has also implemented a robust REAP / Escalation Policy which details very clearly the actions to be taken within the Emergency Operations Centre and by Operational staff in line with demand.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Implementing the new ambulance response standards requires £10.4 million recurrent investment; the £3.9 million shortfall prevents full delivery pending funding discussions.
Verbatim wording from the response “Delivery of the new ambulance response standards is dependent on receipt of a recurrent annual cost of investment of £10.4 million, identified from the ORH report, of which:” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
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 Commissioners control withdrawal of £1.3 million from the emergency operations centre and will address resulting safety concerns after NHS111 procurement.
Verbatim wording from the response “Separately, we have raised a significant patient safety concern with commissioners over their decision to withdraw £1.3 million from our 999 emergency operations centre by September 2018. This removes a significant number of clinical support advisers to our 999 call takers and dispatchers. Commissioners have communicated that they will address our concerns in September 2018 after the completion of the NHS111 procurement process in the North East of England.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
27 Feb 2018 Kevan FUNNELL · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Unavailability of responders for the designated response timeframe View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kevan FUNNELL · 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
Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose in this case.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of responders for the designated response timeframe
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival.
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time .
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them.
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls.
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” Source location Kevan FUNNELL · 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 Improve demand forecasting so available ambulance and crew hours more closely match service demand.
Verbatim wording from the response “In addition, the demand for our services on the night in question was greater than had been forecast. Since then, there has been much improvement in how we forecast and during 2018 the ambulance and crew hours we have available much more closely match the level of demand.” Source location Response from South East Coast Ambulance Service
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 Work with commissioners on a jointly commissioned demand and capacity review to align resource requirements with service demand.
Verbatim wording from the response “To summarise, it is clear that there was an error with the original classification of Mr Funnell and then a failure to upgrade his call. For this, I am sorry. Although this was human error, the recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring. We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.” Source location Response from South East Coast Ambulance Service
Open published response
26 Jan 2018 Andrew Stephen Finlay · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1
Failure to ensure timely dispatch and arrival of ambulance crews in response to 999 calls View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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. 10
North East Ambulance Service NHS Foundation Trust
Complete a recruitment campaign to reduce paramedic vacancies and reach the workforce-plan establishment.
View source
North East Ambulance Service NHS Foundation Trust
Secure funding for resources to recruit 84 additional staff, including 42 paramedics and 42 clinical care assistants.
View source
North East Ambulance Service NHS Foundation Trust
Run regular paramedic training courses across the financial year and schedule additional courses to meet pipeline demand.
View source
North East Ambulance Service NHS Foundation Trust
Conduct regular paramedic assessment dates.
View source
North East Ambulance Service NHS Foundation Trust
Operate three double-crewed ambulances on daily afternoon and evening shifts in locations aligned with demand.
View source
North East Ambulance Service NHS Foundation Trust
Commission and complete a demand and capacity review for the Ambulance Response Programme workforce requirements.
View source
North East Ambulance Service NHS Foundation Trust
Discuss additional resource requirements with the Lead Commissioner and submit a formal contract variation.
View source
North East Ambulance Service NHS Foundation Trust
Tackle hospital handover-to-clear delays, which have already been reduced by nearly 20%.
View source
North East Ambulance Service NHS Foundation Trust
Reduce sickness absence and staff abstraction.
View source
North East Ambulance Service NHS Foundation Trust
Work with acute hospitals to reduce handover delays.
View source See 7 more actions
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AI-generated summary
Andrew Stephen Finlay · 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
Andrew Stephen Finlay, aged 54, collapsed at home on 13 December 2016 and died there the following day. Although expert evidence indicated that the delay in dispatching and arriving with an ambulance did not affect the outcome, concerns remained about delays in emergency ambulance responses, including ongoing paramedic vacancies.
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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 ensure timely dispatch and arrival of ambulance crews in response to 999 calls
Wider context from the report “However, it is the 2nd such Report in recent months that I have written about the timely despatch and arrival of an ambulance crew in response to a 999 call.
I heard evidence about the reviews of procedures undertaken since Andrew’s death, but I still have concerns.
Although the plans for the recruitment and retention of personnel and the purchase of additional vehicles were encouraging to hear evidence about, I was told there were still 32 paramedic vacancies to be filled a year after Andrew’s death.
For Andrew the delay made no difference, but for someone else it might. Accordingly it is my duty to write this Report to you, particularly as it may add impetus to the improvement plan.
” Source location Andrew Stephen Finlay · 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 Complete a recruitment campaign to reduce paramedic vacancies and reach the workforce-plan establishment.
Verbatim wording from the response “Through the completion of a robust recruitment campaign, the Trust reduced the 20% vacancy rate and reached full establishment against its 16/17 workforce plan in March 2017.” Source location Andrew-finlay-Response
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 Secure funding for resources to recruit 84 additional staff, including 42 paramedics and 42 clinical care assistants.
Verbatim wording from the response “However, as a result of the CQC published report, following discussions with the Trust Commissioners, the Trust were successful in securing additional funding for the contract year 2017/18 which provided resources to recruit 84 extra staff, this being 42 paramedics and 42 clinical care assistants, along with associated vehicles and equipment. This funding however was not planned for release until October 2017 and February 2018. Our current vacancy rate which reflects this new establishment mentioned above is now at 7%. Our attrition rate has also reduced to 6.98% therefore slowing the number of staff leaving the Trust.” Source location Andrew-finlay-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 Run regular paramedic training courses across the financial year and schedule additional courses to meet pipeline demand.
Verbatim wording from the response “In order to close this vacancy rate we have regular paramedic training courses planned across the financial year, with courses commencing in April, June, September, October 2018 and February 2019. The number of courses is regularly reviewed and additional courses scheduled to meet the demands of the paramedic pipeline.” Source location Andrew-finlay-Response
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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 Conduct regular paramedic assessment dates.
Verbatim wording from the response “We have 41 graduates from Teesside University who will be available to commence practice from September 2018. In addition the Trust have regular paramedic assessment dates planned and are looking at a further proactive advertising campaign to include social media adverts in order to attract paramedics to the region.” Source location Andrew-finlay-Response
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 Operate three double-crewed ambulances on daily afternoon and evening shifts in locations aligned with demand.
Verbatim wording from the response “There are 3 new double crewed ambulances that have been running since November 2017 covering a 14:00-02:00 shift daily. This is where our demand profile has increased with our peak demand falling into early afternoon and evening. These vehicles are spread geographically across our area based on our demand profile” Source location Andrew-finlay-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 Commission and complete a demand and capacity review for the Ambulance Response Programme workforce requirements.
Verbatim wording from the response “It was acknowledged however by our commissioners, that further demand and capacity profiling would need to be carried out as a result of the introduction of the new Ambulance Response Programme (ARP) in October 2017 and that the 84 extra staff would likely not meet the overall workforce gap.” Source location Andrew-finlay-Response
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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 Discuss additional resource requirements with the Lead Commissioner and submit a formal contract variation.
Verbatim wording from the response “As a result, the Trust and Lead Commissioner jointly commissioned a demand and capacity review which was published in January 2018. The review identified further resource, 79 paramedics and associated equipment, vehicles and support staff, is still required over and above the previously agreed 42 paramedics in order to meet the new Ambulance Response Programme targets. The Trust is therefore now in discussions with their Lead Commissioner on how to progress this and a formal contract variation has been submitted.” Source location Andrew-finlay-Response
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 Tackle hospital handover-to-clear delays, which have already been reduced by nearly 20%.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
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 Reduce sickness absence and staff abstraction.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
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 Work with acute hospitals to reduce handover delays.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
Open published response
17 Nov 2017 Kathryn Verina Richmond · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure to stagger ambulance crew shifts and meal breaks View source
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AI-generated summary
Kathryn Verina Richmond · 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
Kathryn Verina Richmond collapsed at home on 21 April 2015, was taken to hospital after delays in ambulance attendance, and died that morning despite lifesaving treatment for a ruptured spleen. The principal concern was that non-staggered ambulance crew shifts led to simultaneous meal breaks, reducing available resources and potentially delaying responses to emergency calls.
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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 stagger ambulance crew shifts and meal breaks
Wider context from the report “i. Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts , there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time .
” Source location Kathryn Verina Richmond · 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 Make the National Directors of Operations Group aware of the concerns and remind it to review rostering arrangements regularly.
Verbatim wording from the response “AACE will ensure that the National Directors of Operations Group (NDOG) is made aware of your concerns associated with this tragic incident and remind them of the need to ensure that this is done on a regular basis.” Source location 2017-0401-Response-by-Department-of-Health
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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 Department does not issue specific guidance on ambulance rostering structures or meal-break arrangements.
Verbatim wording from the response “I can confirm that the Department of Health and Social Care does not issue specific guidance to ambulance trusts on the structure of their rostering systems or meal break arrangements. Neither does the AACE have the power to mandate ambulance trusts to make changes to their operating practices. Paramedic meal breaks and shift pattern arrangements are operational matters for individual ambulance trusts.” Source location 2017-0401-Response-by-Department-of-Health
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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 Association lacks authority to mandate ambulance trusts to change their operating practices.
Verbatim wording from the response “Firstly, can I be clear that the Association of Ambulance Chief Executives (AACE) has no power to mandate Ambulance Trusts nationally to make changes to their operating practices which remain a matter for individual trusts and their respective Boards.” Source location 2017-0401-Response-by-Department-of-Health
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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 Existing arrangements require trusts to stagger breaks where possible, review rosters regularly, and provide emergency interruption options.
Verbatim wording from the response “However, I am advised that all ambulance services are aware of the need to stagger meal breaks as much as possible and to regularly review rostering systems to stagger start and finish times and therefore meal breaks. In addition, all ambulance services have arrangements in place to enable clinicians to be interrupted during their breaks in the event of a major incident, and all services have additional arrangements for crews to be disturbed during a break on a voluntary basis to respond to potentially life-threatening calls.” Source location 2017-0401-Response-by-Department-of-Health
Open published response
4 Sep 2017 Anthony William McCormack · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1
Failure of ambulance services to meet nationally set emergency response-time targets View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anthony William McCormack · 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
Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ambulance services to meet nationally set emergency response-time targets
Wider context from the report “• I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources in November 2015 (for provision of more ambulances and recruitment of an additional 400 staff) I was also informed since April 2017 none of the nationally set targets have been met by any ambulance trust in England and Wales namely, a Red 1 response within 8 minutes 75% of the time, Red 2 within 19 minutes 95% of the time, I was also informed that there has been a massive increase of calls to 999 with consequent impact on response times and delays in ambulance turnaround at hospitals.
” Source location Anthony William McCormack · Prevention of Future Deaths report
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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 Agree to implement an improved ambulance performance framework with national response standards and prioritised responses for the sickest patients.
Verbatim wording from the response “I would like to take this opportunity to highlight that, following an independent evaluation of extensive trials, we have agreed NHS England’s recommendation to implement an improved ambulance performance framework, which:” Source location 2017-0241-Response-by-Department-of-Health
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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 Improve ambulance-trust productivity and efficiency through the ambulance improvement programme.
Verbatim wording from the response “The Department continues to work closely with NHS England and NHS Improvement to monitor and support performance in 2017-18, and there is a range of ambulance improvement programme work underway. This includes work to improve the clinical capability and conditions for paramedics; commissioning and operating models for ambulance services; and ambulance trust productivity and efficiency.” Source location 2017-0241-Response-by-Department-of-Health
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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 Provision of emergency ambulance services is assigned to the local NHS, including the North West Ambulance Service and its commissioners.
Verbatim wording from the response “I should explain that the provision of emergency ambulance services is a matter for the local NHS. My officials have made enquiries with the North West Ambulance Service NHS Trust and the NHS Blackpool Clinical Commissioning Group (CCG), as lead commissioner for ambulance services in the North West region.” Source location 2017-0241-Response-by-Department-of-Health
Open published response
Concerns raised 1
Continuing ambulance delays View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB Welsh Ambulance Services NHS 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. 10
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Operate the clinical response model that prioritises life-saving ambulance calls and provides bespoke responses for other patients.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Operate the Clinical Support Desk to provide telephone clinical triage and direct patients to appropriate care pathways.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Increase Clinical Support Desk staffing by up to 30 whole-time equivalents using secured Welsh Government funding.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Introduce Treatment Escalation Plans for nursing and residential homes to support safe care without ambulance conveyance.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Implement an escalation protocol for safely managing delayed ambulance handovers and releasing ambulances for urgent calls.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Operate the Local Escalation Action Plan to minimise ambulance handover delays, including hospital liaison support.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Use demand-management communications and escalation between ambulance and hospital senior managers during handover delays.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Apply paramedic guidance for identifying patients suitable for handover to the ED waiting room.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Provide triage, medical review, harm review, and physiological monitoring for patients delayed in ambulances at Ysbyty Glan Clwyd.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Develop guidance for ambulance resources supporting patient discharge, transfer, routine transport, and repatriation.
View source See 7 more actions
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AI-generated summary
Daphne Edith Williams · 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
Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her death.
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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 Continuing ambulance delays
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” Source location Daphne Edith Williams · 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 Operate the clinical response model that prioritises life-saving ambulance calls and provides bespoke responses for other patients.
Verbatim wording from the response “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time.
All other patients receive a bespoke clinical response based on their condition, rather than a response based solely on a time standard. These changes sought to improve the patient’s care, outcome and experience, as well as improve patient flow into hospitals.” Source location 2017-0167-Response-by-University-Health-Board
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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 Operate the Clinical Support Desk to provide telephone clinical triage and direct patients to appropriate care pathways.
Verbatim wording from the response “1.2. Increase effectiveness of the Clinical Support Desk
As the result of a service improvement initiative, WAST has invested in a Clinical Support Desk within the Clinical Contact Centre (CCC). This means that a clinician (nurse / paramedic) is available to clinically assess, through telephone triage, the needs of patients and advise on appropriate alternative care pathways or conveyance. This initiative has proved highly successful, resulting in an average of 2,500 calls per month having a non-ambulance outcome, thereby substantially reducing ambulance conveyances to hospital. Following the success of this initiative, WAST has successfully presented a business case to the Ambulance Services Commissioner and Welsh Government and has received funding from Welsh Government to increase the clinicians employed in the clinical support desk for up to 30 whole time equivalents.” Source location 2017-0167-Response-by-University-Health-Board
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 Increase Clinical Support Desk staffing by up to 30 whole-time equivalents using secured Welsh Government funding.
Verbatim wording from the response “1.2. Increase effectiveness of the Clinical Support Desk
As the result of a service improvement initiative, WAST has invested in a Clinical Support Desk within the Clinical Contact Centre (CCC). This means that a clinician (nurse / paramedic) is available to clinically assess, through telephone triage, the needs of patients and advise on appropriate alternative care pathways or conveyance. This initiative has proved highly successful, resulting in an average of 2,500 calls per month having a non-ambulance outcome, thereby substantially reducing ambulance conveyances to hospital. Following the success of this initiative, WAST has successfully presented a business case to the Ambulance Services Commissioner and Welsh Government and has received funding from Welsh Government to increase the clinicians employed in the clinical support desk for up to 30 whole time equivalents.” Source location 2017-0167-Response-by-University-Health-Board
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 Treatment Escalation Plans for nursing and residential homes to support safe care without ambulance conveyance.
Verbatim wording from the response “Complimenting this work by WAST are a range of BCUHB initiatives to reduce ambulance conveyance/ED attendance. These include:” Source location 2017-0167-Response-by-University-Health-Board
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 Implement an escalation protocol for safely managing delayed ambulance handovers and releasing ambulances for urgent calls.
Verbatim wording from the response “BCUHB has developed an escalation protocol to ensure a consistent approach to the safe management of patients whose handover is delayed. This is to support the procedure to enable the immediate release of delayed ambulances to enable WAST to respond to life threatening or clinically urgent 999 calls in the community (the immediate release system).” Source location 2017-0167-Response-by-University-Health-Board
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 Operate the Local Escalation Action Plan to minimise ambulance handover delays, including hospital liaison support.
Verbatim wording from the response “With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which clearly outlines the escalation processes for WAST and BCUHB staff to apply to enable ambulance crews to hand over patients to ED with minimum delay. As part of the ‘LEAP’ protocol, WAST provides a Hospital Ambulance Liaison Officer (HALO) or a Duty Operational Manager (DOM) at hospitals when ambulances are delayed. These are usually WAST Clinical Team Leaders whose role is to supervise crews experiencing handover delays and liaise directly with ED.” Source location 2017-0167-Response-by-University-Health-Board
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 Use demand-management communications and escalation between ambulance and hospital senior managers during handover delays.
Verbatim wording from the response “The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity.
WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.” Source location 2017-0167-Response-by-University-Health-Board
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 Apply paramedic guidance for identifying patients suitable for handover to the ED waiting room.
Verbatim wording from the response “The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity.
WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.” Source location 2017-0167-Response-by-University-Health-Board
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 Provide triage, medical review, harm review, and physiological monitoring for patients delayed in ambulances at Ysbyty Glan Clwyd.
Verbatim wording from the response “For Ysbyty Glan Clwyd, patients who cannot be immediately accommodated into a clinically appropriate ED space will undergo a triage assessment by an ED nurse and a clinical medical review. Patients held in an ambulance for an hour or more will have a full ‘harm’ review to commence assessment/treatment and ensure their care outcome is not compromised. The recording of patients’ vital signs including the National Early Warning Score (NEWS) is routinely recorded as part of these assessments and is integrated into the paramedics’ patient record.” Source location 2017-0167-Response-by-University-Health-Board
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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 guidance for ambulance resources supporting patient discharge, transfer, routine transport, and repatriation.
Verbatim wording from the response “Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process. WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation Guidance’ to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their discharge/transfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
27 Apr 2017 Anton Kusz · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2
Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care View source Delays in providing ambulance responses to urgent 999 calls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anton Kusz · 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
Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.
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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 Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” Source location Anton Kusz · 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 Delays in providing ambulance responses to urgent 999 calls
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent . It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” Source location Anton Kusz · 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 Conduct regular checks, diagnostics and treatment reviews for patients delayed in ambulances to minimise waiting times.
Verbatim wording from the response “15. Regular Review of Patient delayed in Ambulances; to help prevent recurrence of the issues you raised relating to Rebecca Evans a system of regular checks, diagnostics and treatment, has been put in place to ensure patients experience the minimum delay.” Source location 2017-0140-Response-by-University-Health-Board
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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 Coordinate immediate ambulance offload with WAST and emergency departments so ambulances can be released for potentially life-threatening calls.
Verbatim wording from the response “16. Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST) they co-ordinate with emergency department to ensure that ambulances can be released to respond to potentially life threatening calls through immediate offload into any available in ED.” Source location 2017-0140-Response-by-University-Health-Board
Open published response
13 Sep 2016 Keith William Rushton · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Inadequacy of ambulance response times View source
This report raised 1 other concern. 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
Keith William Rushton · 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
Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequacy of ambulance response times
Wider context from the report “• To review and reconsider the adequacy of the existing response times given the two hour delay in responding to Mr Rushton.
” Source location Keith William Rushton · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.