Recurring concern

Failure to ensure timely ambulance access to care and emergency treatment premises

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First reported 9 Sep 2013•Latest report 25 Nov 2024

Definition

What this concern includes

Includes failures of dedicated ambulance-access arrangements at care homes, hospitals, venues or other emergency treatment premises, including staffing, entry systems, access directions and related operational arrangements, when those failures delay or obstruct ambulance access.

Not included

  • Excludes general ambulance response delays or shortages unrelated to gaining entry to the destination premises.
  • Excludes hospital handover delays after ambulance arrival.
  • Excludes generic building security or access-control failures unless they specifically obstruct ambulance access.
  • Excludes failures of clinical assessment, treatment, information transfer or patient transfer that do not concern ambulance access to premises.
Reports
5

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
11

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.

Ambulnz Community Partners Ltd.1
Care Quality Commission1
Castlehill Specialist Care Centre1
Department of Health and Social Care1
First Aid Cover Ltd1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Northern Care Alliance NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Office of the Chief Coroner1
South Central Ambulance Service NHS Foundation Trust1
The Roundhouse Trust1
White Branch Live Ltd1
Woodhill Prison1

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. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Dean John Mark Anthony BRAY · 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

    Dean Bray died of acute heart failure on 29 December 2021 while in the seclusion room on Hamtun Ward. The report identified failures to adequately monitor and escalate his high respiratory rate, and concerns about the ability to make emergency calls from the observation room and delays accessing the seclusion area.

    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 ensure that the ward's immediate access route is known and shared with emergency ambulance services

    Wider context from the report

    “Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House. ”

    Source location

    Dean John Mark Anthony BRAY · 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

    Agree a process with South Central Ambulance Service for updating emergency access information in its dispatch system.

    Verbatim wording from the response

    “Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.”

    Source location

    Hampshire and IOW Healthcare NHS
    Page 1 · response
    Published 28 November 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide South Central Ambulance Service with emergency meeting locations for all Trust inpatient units.

    Verbatim wording from the response

    “Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.”

    Source location

    Hampshire and IOW Healthcare NHS
    Page 1 · response
    Published 28 November 2024

    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

    Meet ambulance crews and escort them to the emergency location whenever they attend a Trust inpatient unit.

    Verbatim wording from the response

    “In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.”

    Source location

    Hampshire and IOW Healthcare NHS
    Page 2 · response
    Published 28 November 2024

    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

    Update emergency access information with South Central Ambulance Service annually or when additional inpatient units are added.

    Verbatim wording from the response

    “In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.”

    Source location

    Hampshire and IOW Healthcare NHS
    Page 2 · response
    Published 28 November 2024

    Open published response
  2. Black Country

    AI-generated summary

    Eric Harold Bird · 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

    Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide timely out-of-hours access to the care home for ambulances

    Wider context from the report

    “5. On arrival the ambulance was unable to gain access to the care home until 22.11 as there was no answer at the door. I heard evidence at the inquest that arrangements had now been made for a staff member to wait in the reception area when an ambulance is now called out of hours to facilitate entry; ”

    Source location

    Eric Harold Bird · 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

    Install corridor monitoring screens linked to the external doorbell with audible alerts to improve timely building access.

    Verbatim wording from the response

    “In order to aid timely access to the building we have fitted several new monitoring screens throughout the corridors linked to the external door bell with an audible alert.”

    Source location

    2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
    Page 1 · response
    Published 4 May 2021

    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

    CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.

    Verbatim wording from the response

    “• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.”

    Source location

    2021-0122-Response-from-Care-Quality-Commission-Redacted
    Page 3 · response
    Published 4 May 2021

    Open published response
  3. Inner North London

    AI-generated summary

    César Cuauhtémoc González Barrón · 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

    César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide ambulance crews with correct venue access directions

    Wider context from the report

    “3. In the event, the instructions given to the London Ambulance Service did not include the direction to drive round to the rear entrance and so valuable minutes were lost as the paramedics made their way from front to rear on foot outside the building. ”

    Source location

    César Cuauhtémoc González Barrón · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Milton Keynes

    AI-generated summary

    William VICKERS · 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

    William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

    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 ensure unobstructed ambulance access through all security gates

    Wider context from the report

    “During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident. Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient. The present system in my view puts prisoners’ lives at risk. ”

    Source location

    William VICKERS · 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

    Update emergency vehicle contingency plans with immediate ambulance notification, gate staffing, additional OSG support, proportionate searching, and information sharing to prevent access delays.

    Verbatim wording from the response

    “Since Mr Vickers’ inquest the contingency plans at HMP Woodhill have been updated to ensure that there are no delays to the process of receipt of any emergency vehicle, including ambulances during night state. When a code red or blue is called, the control room contacts South Central Ambulance Service (SCAS) immediately. When this occurs during night state, members of staff report to the prison gate to await the arrival of the ambulance, and to assist the responding dog handler with opening the gates to the units.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide all Custodial Managers an opportunity to participate in a live test of emergency vehicle receipt arrangements.

    Verbatim wording from the response

    “All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 9 September 2019

    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

    Deliver establishment-based training for OSGs on emergency vehicle receipt arrangements, with completion required for all OSGs by the end of 2019.

    Verbatim wording from the response

    “All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 9 September 2019

    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

    Establish a joint prison access process to provide ambulance crews with timely access to patients and identify expected emergency resources.

    Verbatim wording from the response

    “2. Access to the prisoner (patient).”

    Source location

    2019-0255-South-Central-Ambulance-Service-NHS-Trust
    Page 4 · response
    Published 9 September 2019

    Open published response
  5. Manchester South

    AI-generated summary

    Martin Daffydd 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

    Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.

    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 ambulance crew access to coded hospital entrance keypads

    Wider context from the report

    “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to. ”

    Source location

    Martin Daffydd Barker · 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 maintain continuous staffing of resuscitation receptions

    Wider context from the report

    “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to. ”

    Source location

    Martin Daffydd Barker · 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

    Share the case with the Care Quality Commission for consideration of emergency-department access arrangements in independent ambulance-service inspections.

    Verbatim wording from the response

    “As you will appreciate, independent providers of ambulance services do not fall directly within the remit of the Department of Health. They are however required to register with, and be inspected by, the Care Quality Commission. I therefore propose to share this case with the CQC so that they can consider whether adequate arrangements for access to emergency departments need to be part of the inspection portfolio for such organisations. Patients might reasonably expect independent ambulance providers to have in place arrangements to access emergency departments to which they might be required to take patients, and that reasonable access should be granted.”

    Source location

    2013-0226-Response-by-Department-of-Health
    Page 3 · response
    Published 29 January 2014

    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

    Write to the Health and Safety Executive to bring the case to its attention regarding independent ambulance-service access to receiving emergency departments.

    Verbatim wording from the response

    “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.”

    Source location

    2013-0226-Response-by-Department-of-Health
    Page 3 · response
    Published 29 January 2014

    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

    Independent ambulance providers do not fall directly within the Department of Health’s remit.

    Verbatim wording from the response

    “As you will appreciate, independent providers of ambulance services do not fall directly within the remit of the Department of Health. They are however required to register with, and be inspected by, the Care Quality Commission. I therefore propose to share this case with the CQC so that they can consider whether adequate arrangements for access to emergency departments need to be part of the inspection portfolio for such organisations. Patients might reasonably expect independent ambulance providers to have in place arrangements to access emergency departments to which they might be required to take patients, and that reasonable access should be granted.”

    Source location

    2013-0226-Response-by-Department-of-Health
    Page 3 · response
    Published 29 January 2014

    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

    Licensing and medical-cover arrangements at public events are the responsibility of local authorities.

    Verbatim wording from the response

    “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.”

    Source location

    2013-0226-Response-by-Department-of-Health
    Page 3 · response
    Published 29 January 2014

    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

    Amending the Purple Guide to specify independent ambulance access arrangements is ultimately for the HSE to decide.

    Verbatim wording from the response

    “I therefore intend to write to the HSE to bring this case to their attention. Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application. However this would ultimately be a matter for the HSE to decide.”

    Source location

    2013-0226-Response-by-Department-of-Health
    Page 3 · response
    Published 29 January 2014

    Open published response
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Data last updated 7 September 2026