9 May 2023 Sandra Dianne Finch · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure of ambulance categorisation pathways to allow movement away from rigid categories 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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Sandra Dianne Finch · 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
Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 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 of ambulance categorisation pathways to allow movement away from rigid categories
Wider context from the report “1. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path . This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly .
” Source location Sandra Dianne Finch · 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 Operate a clinical validation process that triages category 3 and 4 incidents, routes patients to appropriate outcomes, and increases ambulance response categories where clinically indicated.
Verbatim wording from the response “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, led to the clinical validation team becoming a substantiated process within the Trust.” Source location Response from West Midlands Ambulance Service
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have senior clinical navigators risk-assess patients awaiting clinical assessment, arrange ambulance dispatch for unsuitable patients, and upgrade incidents when indicated.
Verbatim wording from the response “All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily.” Source location Response from West Midlands Ambulance Service
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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 clinical validation, prioritisation, risk assessment and escalation arrangements are considered sufficient to manage category 3 and 4 delays safely.
Verbatim wording from the response “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, led to the clinical validation team becoming a substantiated process within the Trust.” Source location Response from West Midlands Ambulance Service
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19 Apr 2023 DAVID ERNEST MASON · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Call-handler pathway failing to consider adrenal crisis risk after trauma View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association of Ambulance Chief Executives NHS England Society For Endocrinology West Midlands Ambulance Service University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Society For Endocrinology
Liaise with JRCALC to align ambulance protocols and clarify additional oral or intramuscular hydrocortisone for trauma or injury.
View source
Society For Endocrinology
Work with ambulance, 999 and 111 services through NHSE to include steroid emergency information in call-handler triage and support category 2 ambulance dispatch.
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West Midlands Ambulance Service University NHS Foundation Trust
Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.
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NHS England
Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
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NHS England
Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
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DAVID ERNEST MASON · 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
David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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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 Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS .
” Source location DAVID ERNEST MASON · 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 Liaise with JRCALC to align ambulance protocols and clarify additional oral or intramuscular hydrocortisone for trauma or injury.
Verbatim wording from the response “The Society for Endocrinology will have opportunity to review this when it is shared with stakeholders and provide comments. Also, members of the Society for Endocrinology are on the committee writing the guidelines and will ensure these topics are covered. In terms of Ambulance service, JRCALC has protocols advising on the management of patients with adrenal insufficiency. ████████ is liaising with them, at present and we will ensure all protocols align and are clear about the need to give additional oral or IM hydrocortisone in trauma/injury. JRCALC guidelines state anyone can give IM hydrocortisone and we are aware that there is an issue around paramedics and technicians being reminded both groups can administer emergency treatment. This is important as different types of ambulance have different health care professionals working on them.” Source location Response from Society for Endocrinology
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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 Work with ambulance, 999 and 111 services through NHSE to include steroid emergency information in call-handler triage and support category 2 ambulance dispatch.
Verbatim wording from the response “In terms of the NHSE steroid emergency card, the wording states injury/shock. We will continue our work with both ambulance services and 999/111 services via NHSE patient safety team to ensure this is on the triage information to call handlers so a category 2 ambulance can be sent. All ambulances carry hydrocortisone, and both paramedics and ambulance technicians are able to administer IM hydrocortisone so this should not be a blocker to administration. JRCALC may be able to address this in their guidelines. It is possible thatmore work is needed to disseminate the information available and we can continue working with RCP Patient Safety Committee and NHSE Patient Safety team in this regard. We will also update our resources accordingly.” Source location Response from Society for Endocrinology
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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 Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.
Verbatim wording from the response “Response
Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).” Source location Response from West Midlands Ambulance Service
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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 Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
Verbatim wording from the response “However, having learned of this case, NHS Pathways will engage with its stakeholders and monitor emerging evidence and guidelines with respect to emergency steroid replacement therapy in the pre-hospital setting, with a view to making system changes where appropriate in accordance with the governance framework. If it is established that system-wide changes are required, NHS Pathways will work closely with colleagues in the ambulance sector to ensure safety-netting advice is appropriate.” Source location Response from NHS England
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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 Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
Verbatim wording from the response “NHS England will also engage with Medical Priority Dispatch System, the suppliers of the alternative telephone and digital triage system used by ambulance services in England, to review their processes for assessing adrenal insufficiency.” Source location Response from NHS England
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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 Ambulance hydrocortisone availability and authorised personnel should not prevent administration during trauma or injury.
Verbatim wording from the response “In terms of the NHSE steroid emergency card, the wording states injury/shock. We will continue our work with both ambulance services and 999/111 services via NHSE patient safety team to ensure this is on the triage information to call handlers so a category 2 ambulance can be sent. All ambulances carry hydrocortisone, and both paramedics and ambulance technicians are able to administer IM hydrocortisone so this should not be a blocker to administration. JRCALC may be able to address this in their guidelines. It is possible thatmore work is needed to disseminate the information available and we can continue working with RCP Patient Safety Committee and NHSE Patient Safety team in this regard. We will also update our resources accordingly.” Source location Response from Society for Endocrinology
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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 WMAS cannot change the nationally required NHS Pathways triage system used to assess 999 calls.
Verbatim wording from the response “Response
Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).” Source location Response from West Midlands Ambulance Service
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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 NHS Pathways design is considered sufficient because extra adrenal-insufficiency questioning could delay care or create confusion.
Verbatim wording from the response “The majority of calls taken using NHS Pathways are handled by a highly trained but non-clinical Health Advisor. Health Advisors (as per the NHS Pathways Provider Licence) should have access to support from clinicians to support safe call-handling. Even though thorough training is provided, it is not within the remit of the Health Advisor to be trained in, or understand more complex medical elements, such as in this case. Indeed, such enquiry and added confusion delays the management of the case and triaging process. It is for these reasons that questions on past medical history or pharmacology are utilised sparingly across the system, and only where it is deemed that a clear understanding can be sought.” Source location Response from NHS England
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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 AACE has no responsibility for changing the NHS Pathways system used to assess 999 calls in the West Midlands.
Verbatim wording from the response “With regard to your second matter of concern about the advice given in ambulance control centres to people who call 999. Calls to 999 in the West Midlands region are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP) and therefore we have no responsibility for making changes to this system. We are aware from West Midlands ambulance service that the matter has been raised with NHSP. We are however aware of the development of an educational e learning package for call handlers so they have a better understanding and awareness of Addison’s disease and steroid dependent patients. The package will be trialled in Yorkshire and is being developed in conjunction with The Pituitary Foundation.” Source location Response from Association of Ambulance
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25 Jan 2023 Rita Maureen TAYLOR · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to upgrade emergency incident categorisation when clinical deterioration warranted a higher priority 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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Rita Maureen TAYLOR · 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
Rita Maureen TAYLOR suffered an unwitnessed fall at home and a head injury. Multiple ambulance calls were made, but an ambulance was delayed because no resources were available; she arrived at hospital with a Glasgow Coma Score of 3 and died the same day. The principal concern was insufficient ambulance service resources and the resulting delay, which the inquest conclusion described as causing lost opportunities to admit her and begin treatment.
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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 upgrade emergency incident categorisation when clinical deterioration warranted a higher priority
Wider context from the report “I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.
The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. [At] that time there were "no available resources to send."
At 11.12 a 999 call was made by a passer by but there were still "no available resources ".
At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ".
At 12.41 a call was made to Mrs. Taylor’s location but there were " still no available resources to send".
At 13.12 A further 999 call was made " awaiting resources to become available"
At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources".
At 14.42 further 999 call but again "no available resources".
At 15.25 Case reviewed to a category 2.
At 16.29 An ambulance was dispatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade.
Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Coma score was recorded as 3.She died later the same day.
” Source location Rita Maureen TAYLOR · Prevention of Future Deaths report
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20 Jan 2023 Dorothy Anne Jones · Prevention of Future Deaths report Gwent
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Concerns raised 1
Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness 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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Dorothy Anne Jones · 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
Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.
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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 of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
Wider context from the report “4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed , under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response .
” Source location Dorothy Anne Jones · 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 Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Verbatim wording from the response “To ensure that the Welsh Ambulance Services NHS Trust (WAST) maintains a clinically safe response to patients, regular reviews are undertaken of current Medical Priority Dispatch System (MPDS) code categorisation by the Clinical Priority Assessment Software (CPAS) group.” Source location Response from Welsh Ambulance Services NHS Trust
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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 Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Verbatim wording from the response “I note you have also written to ████████, Chief Executive of the Welsh Ambulance Services Trust and I would expect him to respond on the detail of the concerns you raised as these relate to operational matters and are best addressed by the Trust. I can, however, outline the actions being taken by the Welsh Government to drive national and local improvement in the delivery of safe and timely ambulance services.” Source location Response from Minster for Health and Social Services
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17 Jun 2022 Gwynne SAMUEL · Prevention of Future Deaths report Gwent
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Concerns raised 1
Failure to account for the clinical ramifications of prolonged lying in elderly patients during ambulance categorisation 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
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. 6
Welsh Ambulance Services NHS Trust
Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
View source
Welsh Ambulance Services NHS Trust
Continually review and update dispatch guidance for falls and frailty responders.
View source
Welsh Ambulance Services NHS Trust
Refer categorisation of elderly patients affected by prolonged immobility after falls to the Clinical Priority Software Advisory Group.
View source
Welsh Ambulance Services NHS Trust
Provide enhanced Clinical Desk capacity for targeted telephone advice to patients awaiting responses, including pressure-ulcer prevention and reduced immobility.
View source
Welsh Ambulance Services NHS Trust
Review post-fall patient guidance and immobility risks through the Older Persons Improvement Group, then suggest improvements.
View source
Welsh Ambulance Services NHS Trust
Monitor the three new falls MPDS code suffixes and review data to consider recommendations on differentiated priorities.
View source See 3 more actions
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Gwynne SAMUEL · Prevention of Future Deaths report
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Report summary
Gwynne Samuel, a 95-year-old man who lived alone, fell at home and waited approximately 12 hours for an ambulance before being taken to hospital. He developed an acute kidney injury attributed to the prolonged lie, which delayed hip surgery; he subsequently developed a chest infection and died from pneumonia. The principal concern was the ambulance response time for a patient categorised as Amber 2 and whether the clinical effects of a prolonged lie in an elderly person were adequately considered during categorisation.
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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 account for the clinical ramifications of prolonged lying in elderly patients during ambulance categorisation
Wider context from the report “GS was an elderly gentleman who had suffered a significant fall. The time it took for an ambulance to arrive and convey him to hospital contributed to his death insofar that the development of an acute kidney injury, which compromised his treatment and general condition, was caused by a long lie.
A report obtained from WAST indicated that GS had been categorised as an Amber 2, which I understand is an urgent clinical priority considered serious but not life threatening.
Whilst I accept that there was no evidence that GS was in immediate peril, it would appear that the clinical ramifications of an elderly person lying for a long period of time are not taken into account during the categorisation process .
Whilst I heard evidence, and understand, the pressures on the ambulance service during the pandemic and the inability to release emergency ambulances due to congestion in hospital emergency departments, the inability to provide an ambulance to a patient determined to be in a serious condition (Amber 2) for 12 hours, puts lives in danger and, as in this case, may contribute to their death.
” Source location Gwynne SAMUEL · 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 Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
Verbatim wording from the response “The Medical Prioritisation Dispatch System (MPDS) does not provide a determinant code based on age within Protocol 17 (falls) which would prevent a specific prioritisation change for elderly patients. The principal role of the Clinical Support Desk (CSD) Clinician is to provide additional clinical triage, advice and support to patients to ensure that they can access the most clinically appropriate care for their urgent and emergency healthcare needs, commonly known as Hear and Treat (H&T). In addition to this principal role, the CSD also undertake a range of other clinical functions in pursuance of maximising patient safety for those awaiting an emergency ambulance. This includes reviewing long waiting patients to maintain patient safety.” Source location Response from Welsh Ambulance Services
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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 Continually review and update dispatch guidance for falls and frailty responders.
Verbatim wording from the response “CSD clinicians have the ability to change the responding priority of an incident based on a secondary clinical assessment, this includes increasing the priority where the patient’s clinical acuity indicates this is appropriate. Dispatch guidelines regarding falls and frailty responders are continually reviewed and updated to ensure maximum utilisation of this valuable resource, part of the CSD role is to provide support to falls assistants following an initial assessment to ensure the correct outcome is reached.” Source location Response from Welsh Ambulance Services
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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 Refer categorisation of elderly patients affected by prolonged immobility after falls to the Clinical Priority Software Advisory Group.
Verbatim wording from the response “The categorisation of elderly patients who suffer falls and are more likely be affected by the risks associated with lengthy periods of immobility, will be referred to the Trust’s Clinical Priority Software Advisory Group.” Source location Response from Welsh Ambulance Services
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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 Provide enhanced Clinical Desk capacity for targeted telephone advice to patients awaiting responses, including pressure-ulcer prevention and reduced immobility.
Verbatim wording from the response “Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.” Source location Response from Welsh Ambulance Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review post-fall patient guidance and immobility risks through the Older Persons Improvement Group, then suggest improvements.
Verbatim wording from the response “This has been delayed due to high levels of escalation within the organisation. However, it will be essential to seek opportunities to increase the levels of utilisation of falls resources, ensuring we are able to maximise response capacity across Wales. The newly formed Older Persons Improvement Group (OPIG), will conduct a review of the guidance provided to patients following a fall, consider the risks associated immobility and will suggest possible improvements, as part of the newly formed group, due to meet in August 2022.” Source location Response from Welsh Ambulance Services
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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 Monitor the three new falls MPDS code suffixes and review data to consider recommendations on differentiated priorities.
Verbatim wording from the response “The recent update to ProQA (the system for monitoring data within MPDS) released on 10th May 2022 has split the MPDS code suffix relating to falls on the ground or floor and added time targets as below:” Source location Response from Welsh Ambulance Services
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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 Current demand pressures mean the Trust is unlikely to send responses or act differently within the newly assigned MPDS time targets.
Verbatim wording from the response “There have been discussions at the National Ambulance Service Medical Executive Directors Group (NASMED) as to whether there should be further MPDS code suffixes for falls longer than two hours. NASMED has also highlighted the issue relating to calls just inside a time target window and calls where there is no further contact as the call does not automatically change if the call falls outside the MPDS code suffix window therefore there will be some patients disadvantaged for not calling back.” Source location Response from Welsh Ambulance Services
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15 Jun 2022 Keith Hopwood · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to categorise ambulance calls accurately for appropriate ambulance dispatch View source Failure of the ambulance call algorithm to direct exploration of concerning symptom responses View source
This report raised 2 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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Keith Hopwood · 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 Hopwood fainted and felt very unwell before calling an ambulance, reporting chest pain during a later call. He was found unresponsive at home and could not be resuscitated; the medical cause of death was myocardial infarction due to stenotic coronary artery atheroma. The concerns included delays and resource pressures in the ambulance service, failure to upgrade the call category, limitations in the call-handling algorithm, the use of a private ambulance not equipped to deal with a cardiac patient, and the handling of a disconnected call when he was alone.
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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 categorise ambulance calls accurately for appropriate ambulance dispatch
Wider context from the report “3. The ambulance that arrived was a private ambulance and not equipped to deal with a cardiac patient. If the second call had been correctly categorised it would not have been dispatched as private ambulances are deployed with less qualified staff to calls categorised as 3 and 4 due to a lack of NHS Ambulance resources. As a consequence a further ambulance had to be deployed to the scene when Mr Hopwood was found to be unresponsive;
” Source location Keith Hopwood · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the ambulance call algorithm to direct exploration of concerning symptom responses
Wider context from the report “2. The inquest heard that in the initial call to the ambulance service he was told to call back if he got worse in any way. His response was to say that he couldn’t feel any worse than he had in the last 10 minutes. The algorithm driving the conversation did not direct that this response should require exploration of symptoms and why he had made this comment . As a consequence an opportunity to explore his presentation further was lost;
” Source location Keith Hopwood · Prevention of Future Deaths report
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7 Mar 2022 Josephine Celia BARKER · Prevention of Future Deaths report Surrey
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Concerns raised 2
Early termination of 999 call triage before completion View source Failure to recognise drowsiness as a new symptom requiring re-triage View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Josephine Celia BARKER · 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
Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.
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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 Early termination of 999 call triage before completion
Wider context from the report “1. The initial early exit of the first 999 call without full triage - this results in a category 3 response. There is no reason full triage could not have continued .
” Source location Josephine Celia BARKER · Prevention of Future Deaths report
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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 recognise drowsiness as a new symptom requiring re-triage
Wider context from the report “9. When Jo was reported as drowsy, this was not considered as a new symptom and she was not re-triaged .
” Source location Josephine Celia BARKER · Prevention of Future Deaths report
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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 NHS Pathways early-exit options and clinical validation arrangements adequately manage complex or incompletely triaged calls.
Verbatim wording from the response “NHS Pathways has a function called ‘Early Exit’ which the health advisors can use for certain scenarios and reasons.” Source location Response from NHS Improvement
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4 Feb 2022 Sarah Marie GILBERT-JONES · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Inconsistent response coding and categorisation leading to unreliable vehicle dispatch decisions 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
Sarah Marie GILBERT-JONES · 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
Sarah Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.
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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 Inconsistent response coding and categorisation leading to unreliable vehicle dispatch decisions
Wider context from the report “(3) Following the second call to Clinical Contact Centre at 23.48 on 28.10.20, there were somewhat bewilderingly complex, & inconsistent categorisations of the code for response which appeared to lead to response vehicles being dispatched or stood down , whilst the patient remained in need of time sensitive treatment by way of transfer to an Accident & Emergency Unit . Whilst I was assured that this had been addressed by learning & guidance to call handlers, a review of categorisations, coding & actions in the setting of a patient demonstrating the symptoms as per the deceased on 28/29 October 2020 to achieve clarity/consistency is invited.
” Source location Sarah Marie GILBERT-JONES · 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 Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.
Verbatim wording from the response “During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident.” Source location 2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
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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 Drug-specific overdose responses cannot be incorporated because drugs vary widely and prioritisation is based on current condition, not potential future deterioration.
Verbatim wording from the response “The issues of investigating different actions for different drug types are twofold. There is the fact that the individual drugs that can be involved in overdose cases are many and varied. Additionally, this moves away from the basis of the Trust’s Clinical Response Model, where the sickest patients are identified and attended first. This Model is based on the patient’s condition at the time and is not based on potential future changes to their conditions.” Source location 2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
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27 Jan 2022 Adam Marshall Elliot STONE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to allow a category 1 ambulance response for severe ABD involving restraint View source
Linked responses
Association of Ambulance Chief Executives College of Paramedics NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
College of Paramedics
Propose that NHS England and AACE consider an evidence-based review of Acute Behavioural Disturbance response categorisation.
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NHS England
Write to ambulance services reminding them to provide senior-clinician oversight for ABD calls and upgrade to Category 1 when deterioration or restraint occurs.
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Association of Ambulance Chief Executives
Conduct a joint police and ambulance review of suspected ABD presentations to assess deterioration risk and appropriate response categories.
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Association of Ambulance Chief Executives
Consider whether restraint alone should trigger an automatic Category 1 response for suspected ABD.
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AI-generated summary
Adam Marshall Elliot STONE · 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
Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.
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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 allow a category 1 ambulance response for severe ABD involving restraint
Wider context from the report “5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk.
” Source location Adam Marshall Elliot STONE · 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 Propose that NHS England and AACE consider an evidence-based review of Acute Behavioural Disturbance response categorisation.
Verbatim wording from the response “I am aware that AACE will also be writing to you in response to your PFD. The College endorses the content of AACE’s letter to you. However, the College would always support an evidence-based review of the current response categorisation of Acute Behavioural Disturbance in order to ensure that a Category 2 response remains the appropriate disposition and I will share this correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose that such a review be considered in the light of this PFD.” Source location 2022-0026-Response-from-College-of-Paramedics_Published
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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 Write to ambulance services reminding them to provide senior-clinician oversight for ABD calls and upgrade to Category 1 when deterioration or restraint occurs.
Verbatim wording from the response “NHS England and NHS Improvement are in the process of writing to ambulance services regarding clinical oversight and will include a reminder that ABD calls should have oversight of a senior clinician in the control room and calls should be upgraded to a Category 1 if the patient’s condition deteriorates or if the patient is being restrained.” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_Published
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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 a joint police and ambulance review of suspected ABD presentations to assess deterioration risk and appropriate response categories.
Verbatim wording from the response “To help inform this decision and provide evidence, a joint police and ambulance review was conducted in the north of England between one ambulance service and a police force for a period of 9 months between August 2019 to May 2020. The purpose of the joint review was to establish whether individual presenting features in patients who were identified by police officers on scene as possible ABD, might individually or in combination reliably identify an increased risk of clinical deterioration associated with increased mortality and to determine the most appropriate ambulance response time category. Police officers identified 28 potential ABD cases in the nine-month review period, representing 1% of the mental health or behavioural crisis 999 calls attended by the police” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 Consider whether restraint alone should trigger an automatic Category 1 response for suspected ABD.
Verbatim wording from the response “We agree that ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of agitation with likely physiological abnormalities, caused by one of a number of possible toxicological, physical, or mental health conditions. In the prehospital setting we are often unable to ascertain the exact cause of the presentation while providing clinical care prior to arrival at an emergency department. We considered whether the use of restraint alone should warrant an automatic Category 1 response, but this was agreed through the ECPAG process as not appropriate unless immediately life-threatening signs were present.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 NHS Pathways recognises ABD and restraint risks and complies with the nationally mandated Category 2 response standard.
Verbatim wording from the response “We would like to reassure you that NHS Pathways recognises the risks associated with ABD/Excited Delirium and also that restraint may be a factor contributing to a patient’s deterioration.” Source location 2022-0026-Response-from-NHS-Digital_Published
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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 Any change to ambulance response categorisation must be considered by NHS England and AACE groups and approved by ECPAG.
Verbatim wording from the response “Therefore, any change in ambulance response categorisation would be matters for the respective” Source location 2022-0026-Response-from-NHS-Digital_Published
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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 Responsibility for determining NHS ambulance response categories lies with NHS England, supported by AACE evidence and guidance.
Verbatim wording from the response “The College of Paramedics is also not responsible for determining NHS ambulance response categories. That power lies with NHS England, although the Association of Ambulance Chief Executives (AACE) provide evidence and guidance to support this.” Source location 2022-0026-Response-from-College-of-Paramedics_Published
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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 Severe and mild ABD cannot be reliably distinguished during pre-hospital or telephone triage, so severity cannot determine the response category.
Verbatim wording from the response “ABD is not common and it is very difficult to identify the difference between agitation, antisocial behaviour, deliberate violent behaviour and ABD, which is not a specific condition with a set of defined symptoms. There is no reliable way to determine mild or severe ABD in the pre-hospital setting and certainly not on the phone during a triage process.” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Suspected ABD appropriately receives a Category 2 response, with senior clinical oversight and escalation to Category 1 when the patient’s condition warrants it.
Verbatim wording from the response “Category 1 responses are reserved for immediate threat to life illnesses or injuries and ambulances are diverted when en-route to other emergencies in order to respond to Category 1 priorities. Cases of suspected ABD should be assigned a Category 2 response which is the immediate dispatch of an emergency ambulance, however, ambulance services are advised that a senior clinician within the control room should be made aware of the potential ABD incident to assist with decision-” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_Published
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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 AACE cannot decide or mandate emergency response categories and therefore cannot undertake that decision-making work.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 NHS England, through ECPAG, is responsible for deciding appropriate ambulance response categories.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 evidence-based arrangements consider Category 2 appropriate for suspected ABD unless immediately life-threatening signs warrant Category 1; restraint alone does not require Category 1.
Verbatim wording from the response “force. The review concluded that for patients who had been recognised as presenting with symptoms and signs of possible ABD, a Category 2 ambulance response was appropriate, if there was information that there were immediately life-threatening signs present, the patient should then receive a Category 1 ambulance response. The evidence and recommendations were accepted through the ECPAG process and implemented by all the UK ambulance services.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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16 Oct 2020 Sarah Fernyhough · Prevention of Future Deaths report Essex
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Concerns raised 1
Automatic categorisation of abandoned calls as category 3 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
Sarah Fernyhough · 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
Sarah Fernyhough died at home in the early hours of 22 May 2019 after taking an overdose of venlafaxine, amisulpride and hydroxyzine, as well as cocaine, cannabis and alcohol. The report identified a delay in ambulance attendance and concerns about the categorisation of her call, including the failure to ensure that the relevant call recording or full medical information was reviewed by the person able to upgrade its categorisation.
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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 Automatic categorisation of abandoned calls as category 3
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required .
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
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” Source location Sarah Fernyhough · 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 Review the process for abandoned calls, including calls involving potential mental health concerns.
Verbatim wording from the response “The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven’t been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call.” Source location 2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
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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 Introduce and revise the mental health abandoned-call procedure to guide Category 2 responses for patients actively at risk.
Verbatim wording from the response “The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven’t been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call.” Source location 2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
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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 Develop, approve and release an abandoned-call procedure covering Category 2 escalation and mandatory Duty Manager checks, including call-recording review.
Verbatim wording from the response “There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust’s governance and approval process. This will be completed and released in December 2020. Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include:” Source location 2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.