Recurring concern

Unreliable ambulance call triage and re-triage

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First reported 6 Dec 2013•Latest report 11 May 2026

Definition

What this concern includes

Includes failures of the ambulance call triage and re-triage process, including initial clinical validation, categorisation, evidence-based category changes, recognition of new or worsening symptoms, timely re-triage and escalation to a more urgent response.

Not included

  • Excludes generic ambulance response delays or resource shortages where the triage or re-triage decision is not deficient.
  • Excludes failures in communicating dispatch status or expected response times after a triage decision has been made.
  • Excludes downstream ambulance attendance, hospital handover or clinical treatment failures that do not concern ambulance call triage or re-triage.
  • Excludes non-ambulance triage processes unless the report explicitly identifies the same ambulance call triage concern.
Reports
50

Distinct published reports

Individual concerns
61

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
72

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England17
Department of Health and Social Care12
Association of Ambulance Chief Executives8
Welsh Ambulance Services NHS Trust7
London Ambulance Service NHS Trust5
NHS Pathways5
National Ambulance Service Medical Directors4
South East Coast Ambulance Service NHS Foundation Trust4
Emergency Call Prioritisation Advisory Group3
North West Ambulance Service NHS Trust3
College of Paramedics2
East Midlands Ambulance Service NHS Trust2
East of England Ambulance Service NHS Trust2
National Institute for Health and Care Excellence2
NHS West and North London Integrated Care Board2

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.

  1. South Wales Central

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient clinician capacity for timely secondary triage of 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
    Page 1 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Christopher Philip Fields · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients

    Wider context from the report

    “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response, suggests that the algorithms used for coding are not accurate and not fit for purpose. In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied. (NWAS, SECRETARY OF STATE and NHS ENGLAND) ”

    Source location

    Christopher Philip Fields · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.

    Verbatim wording from the response

    “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Trial a new ambulance coding system.

    Verbatim wording from the response

    “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.

    Verbatim wording from the response

    “In regards to AMPDS system, I confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s chest had been ‘concealed in’ this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response. I note that the attending police officers evidence supported that the patient was breathing, conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patient’s condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment). Furthermore this assertion was reinforced by ████████ Pathologist report which supported that the critical injury was sustained during the second assault.”

    Source location

    2016-0194-Response-by-North-West-Ambulance-Service
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.

    Verbatim wording from the response

    “I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.”

    Source location

    2016-0194-Response-by-Department-of-Health
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.

    Verbatim wording from the response

    “However, please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concerns about the design of the product you may wish to contact them direct at the following address:”

    Source location

    2016-0194-Response-by-Department-of-Health
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.

    Verbatim wording from the response

    “I note the response from North West Ambulance Service (NWAS), letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time. It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist’s report.”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

  3. Inner North London

    AI-generated summary

    Caragh Melling · 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

    Caragh Melling collapsed at home after an episode of dizziness and died shortly after arriving at hospital following unsuccessful resuscitation attempts. The ambulance call triage failed to recognise her agonal breathing, and the report raised concerns that the NHS Pathways system lacked a tool to identify inadequate breathing and that it was unclear whether action was being taken to address this.

    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 a triage tool to recognise agonal or inadequate breathing

    Wider context from the report

    “(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing. The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool. They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1). I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken. ”

    Source location

    Caragh Melling · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. South London

    AI-generated summary

    Monica Elaine Lewis-Hinds · 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

    Monica Elaine Lewis-Hinds suffered a seizure at home after midnight on 16 January 2015 and later suffered a further seizure that led to asphyxia, cardiac arrest and death. The concern was that the ambulance call handler did not ascertain the type of seizure, delaying the response, and that the London Ambulance Service triage protocol did not require this question to be asked in all cases.

    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 proactively ask and record the type of fit during triage calls

    Wider context from the report

    “The protocol used by the London Ambulance Service for triage calls includes a question about the type of fit, but the question is not posed by the call handler to the caller, and the section is only completed if the caller offers the information. In view of the potential consequences for the patient, this part of the protocol may require amendment, so that the question is put pre-emptively in all cases. ”

    Source location

    Monica Elaine Lewis-Hinds · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    David Anthony SWEENEY · 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 Anthony Sweeney was found unconscious and vomiting after a public call to the London Ambulance Service on 18 April 2015. The call was incorrectly categorised, an ambulance arrived 1 hour 40 minutes later, and Mr Sweeney suffered a cardiac arrest shortly before its arrival; he died a week later from hypoxic brain injury and acute alcohol toxicity. The principal concern was that the call did not receive red prioritisation and that a recurring theme might be emerging in the handling of calls about unconscious patients.

    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 assign red prioritisation to calls regarding unconscious patients

    Wider context from the report

    “A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation. You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious. I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients. ”

    Source location

    David Anthony SWEENEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Elizabeth Anne Lester · 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

    Elizabeth Anne Lester underwent a total knee replacement and was subsequently readmitted to hospital as an emergency. The report raises concern that the ambulance service’s scripted breathing-difficulties assessment did not ask about chest pain, resulting in a green response on the first call; chest pain was identified during a second call, when the response was escalated to red.

    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

    Omission of chest-pain questions from the breathing-difficulties dispatch card

    Wider context from the report

    “As per National practice, the North West Ambulance Service uses Advanced Medical Dispatch System to prioritise calls, based on the answers to scripted questions. During the first call the call-handler asked the relevant questions and followed the “breathing difficulties” card. This card does not include any question as to whether the patient is suffering any chest pains. The call was allocated a green response and the “high volume script” was also given. In fact the patient was short of breath AND did have chest pains, but this was never enquired about. On the second call to the Ambulance service, this aspect was asked about and the call was escalated to a Red response. It is my firm belief, having come across this same issue in a number of inquests, that there is an omission in the ‘card’ for ALL breathing difficulties and it MUST be amended to include a question about chest pain. Breathing difficulties are frequently as a result of compromised heart and/or lung function and this should be queried. I am told that the local ambulance service cannot alter the wording used but that this must be done by the suppliers of the software. ”

    Source location

    Elizabeth Anne Lester · 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

    AMPDS users must ask Priority Dispatch directly to review and change the system’s call-handling questions.

    Verbatim wording from the response

    “Users of AMPDS must contact Priority Dispatch directly if they feel that an element of the system needs to be reviewed and changed. I understand NWAS has responded to your report suggesting that you write directly to the AMPDS contact at Priority Dispatch UK asking for the changes that you have recommended to be considered. I would support this.”

    Source location

    2015-0204-Response-by-Department-of-Health
    Page 2 · response
    Published 29 May 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Department cannot provide further help implementing the proposed AMPDS call-handling changes.

    Verbatim wording from the response

    “I am sorry that the Department cannot be of any further help in implementing the changes you suggest. However, I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Ms Lester’s death to my attention.”

    Source location

    2015-0204-Response-by-Department-of-Health
    Page 2 · response
    Published 29 May 2015

    Open published response

  7. Inner North London

    AI-generated summary

    Sabrina Stevenson · 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

    Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

    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 implement or consider automated call recategorisation

    Wider context from the report

    “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS; ”

    Source location

    Sabrina Stevenson · Prevention of Future Deaths report
    Page 2 · 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

    Failure to implement or consider clinical re-triaging

    Wider context from the report

    “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS; ”

    Source location

    Sabrina Stevenson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assess the clinical appropriateness and feasibility of automated call re-categorisation.

    Verbatim wording from the response

    “The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 5 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Automated call recategorisation could increase risk by causing inappropriate ambulance dispatches and reducing protection for patients requiring eight-minute responses.

    Verbatim wording from the response

    “The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 5 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing clinical hub staffing, standard operating procedures and surge-management processes are considered sufficient, removing the need for automated call-handling processes.

    Verbatim wording from the response

    “The Clinical Hub has refined and developed its processes, skill mix and staffing levels since its inception on 2 December 2013 and an increased level of staffing within the Clinical Hub in the Emergency Operations Centres has negated the need for any automated processes. Staff have clear standard operating procedures in place for the management of Held call, vulnerable patients and calls being held awaiting assessment. The demand management plan itself has been reviewed and replaced with the surge management plan, which has a number of criteria for allowing progression through the plan and a scored matrix to evidence and inform any decision made.”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 5 · response
    Published 30 March 2015

    Open published response

  8. Inner West London

    AI-generated summary

    Ms Samia Yasmin Shara · 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

    Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.

    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 prevent call takers from downgrading calls to lower-acuity pathways

    Wider context from the report

    “(2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity. ”

    Source location

    Ms Samia Yasmin Shara · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Oxfordshire

    AI-generated summary

    Clive GOULD · 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

    Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

    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 allocate appropriate priorities to ambulance calls

    Wider context from the report

    “(1) The original call made by ████████ was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions. An internal audit of that call suggests that a different priority could have been given to the original call and the presenting concerns of Mr Gould's status. ”

    Source location

    Clive GOULD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Transition from AMPDS to the clinically focused NHS Pathways assessment system.

    Verbatim wording from the response

    “SCAS have recognised that AMPDS is a dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health. The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014.”

    Source location

    2013-0357-Response-by-South-Central-Ambulance-Service
    Page 1 · response
    Published 16 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.

    Verbatim wording from the response

    “SCAS response Currently SCAS operates the Department of Health licensed 999 triage software system called AMPDS. As this is a licensed tool all ambulance responses are determined at a national level. As a Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes. The AMPDS product has been developed by Priority Dispatch Corporation with a comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on a monthly basis. As we currently use AMPDS our Call Takers are required to ask a pre-determined set of verbatim questions.”

    Source location

    2013-0357-Response-by-South-Central-Ambulance-Service
    Page 1 · response
    Published 16 December 2013

    Open published response

  10. Manchester South

    AI-generated summary

    Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report

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

    Report summary

    Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.

    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 of ambulance call-takers to correctly assess breathing and triage calls

    Wider context from the report

    “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances. It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating. The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated. I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit. ”

    Source location

    Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide all Emergency Medical Dispatchers with a six-week training course covering procedures, call taking, first aid, paediatric resuscitation and AMPDS.

    Verbatim wording from the response

    “All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.”

    Source location

    2013-0356-Response-by-North-West-Ambulance-Service
    Page 1 · response
    Published 6 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require Emergency Medical Dispatchers to provide continuing-education and audit-review evidence to maintain certification.

    Verbatim wording from the response

    “All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.”

    Source location

    2013-0356-Response-by-North-West-Ambulance-Service
    Page 1 · response
    Published 6 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for selecting and training ambulance call-taking staff rests with the North West Ambulance Service Trust.

    Verbatim wording from the response

    “I note that you have sent a copy of this Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS). The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS.”

    Source location

    2013-0356-Response-by-Department-of-Health
    Page 2 · response
    Published 6 December 2013

    Open published response
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Data last updated 7 September 2026