Recurring concern

Unreliable Community First Responder coverage and call-out

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First reported 15 Jan 2016•Latest report 24 Jan 2019

Definition

What this concern includes

Includes failures in arrangements dedicated to Community First Responder coverage and call-out, including rostering, availability, mobilisation, dispatch and communication controls where these leave required first-responder assistance unavailable or delayed.

Not included

Excludes generic ambulance or emergency-service capacity and dispatch failures unless Community First Responders are the identified response function.
Excludes general volunteer-management, mobile-network or communication deficiencies unless they directly make Community First Responder coverage or call-out unreliable.
Excludes failures in clinical treatment or later emergency response after an appropriate Community First Responder call-out has occurred.
Excludes unrelated first-aid training or staffing concerns where Community First Responder coverage or mobilisation is not the shared unsafe condition.

Reports: 2
Individual concerns: 4
Date range: 2016–2019
Stated actions: 4

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.

East Midlands Ambulance Service NHS Trust1

NHS Wales Joint Commissioning Committee1

Welsh Ambulance Services NHS Trust1

Welsh Government1

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.

24 Jan2019
Lincolnshire
Concerns raised1
1. Failure to call out first responders
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.
Respondent positions 1
1. Position
  The available Community First Responder could not attend because excessive travel distance fell outside the role’s intended community coverage.
  Stated by East Midlands Ambulance Service NHS TrustUnable to act
AI-generated summary

Olive JOHNSON · 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

Olive JOHNSON died within 24 hours of admission to Pilgrim Hospital on 11 May 2018. The concerns raised relate to the absence of a first responder, emergency response times, how response delays were recorded after regrading, and whether EMAS had sufficient conveying resources to meet its targets.

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 call out first responders
Wider context from the report
“a) Why were no first responder's called out in relation to the deceased? ”
Source location
Olive JOHNSON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The available Community First Responder could not attend because excessive travel distance fell outside the role’s intended community coverage.

Verbatim wording from the response
“a) Why were no First Responders called out in relation to the deceased?”

Source location
2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 1 · response
Published 24 May 2019
Open published response
15 Jan2016
North West Wales
Concerns raised3
1. Lack of an effective rota system for consistent Community First Responder cover
2. Insufficient planning for recruitment and retention of local Community First Responders
3. Unreliable communication for contacting Community First Responders in remote and/or rural areas
This report raised 2 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 4
1. Action
  Coordinate with Community First Responders on available resources and volunteer-service arrangements.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Strengthen leadership arrangements for Community First Responder recruitment.
  Stated by Welsh Ambulance Services NHS TrustStated completed
3. Action
  Run a Community First Responder recruitment campaign and provide adequate training.
  Stated by Welsh Ambulance Services NHS TrustStated planned
1. Action
  Pilot and roll out hand-held devices to improve communication with Community First Responders.
  Stated by Welsh Ambulance Services NHS TrustStated completed
AI-generated summary

Jasmine Ruby Lapsley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

On 19 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of an effective rota system for consistent Community First Responder cover
Wider context from the report
“(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication. ”
Source location
Jasmine Ruby Lapsley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient planning for recruitment and retention of local Community First Responders
Wider context from the report
“(3) Given the difficulties in ambulances arriving at many rural and/or remote areas in North West Wales it is essential that there are sufficient local Community First Responders to arrive promptly at the casualty and provide essential treatment preserving life until an ambulance arrives. WAST should review the planning for the recruitment and retention of Community First Responders. ”
Source location
Jasmine Ruby Lapsley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unreliable communication for contacting Community First Responders in remote and/or rural areas
Wider context from the report
“(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication. ”
Source location
Jasmine Ruby Lapsley · Prevention of Future Deaths report
Page 3 · 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
Coordinate with Community First Responders on available resources and volunteer-service arrangements.

Verbatim wording from the response
“2.4 Current dialogue with CFRs around how best to coordinate use of available resources / identifying list, recognising that this is a volunteer service.”

Source location
2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 4 · response
Published 15 January 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
Strengthen leadership arrangements for Community First Responder recruitment.

Verbatim wording from the response
“2.1 WAST to review and strengthen the leadership arrangements for CFR recruitment.”

Source location
2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 4 · response
Published 15 January 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 Community First Responder recruitment campaign and provide adequate training.

Verbatim wording from the response
“3.2 CFR recruitment campaign and ensure adequate training by the end of spring in readiness for the summer months. Lead: Director of Operations; Assistant Director Operations Evidence: Evidence of a clear plan and additional volunteers Completion: June 2016”

Source location
2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 5 · response
Published 15 January 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
Pilot and roll out hand-held devices to improve communication with Community First Responders.

Verbatim wording from the response
“2.2 Pilot hand-held devices to improve WAST's ability to communicate with CFRs.”

Source location
2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 4 · response
Published 15 January 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to call out first responders

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

Concerns raised3

Lack of an effective rota system for consistent Community First Responder cover

Insufficient planning for recruitment and retention of local Community First Responders

Unreliable communication for contacting Community First Responders in remote and/or rural areas

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.4

Respondent positions 1

Actions described in response 4