Recurring concern

Unreliable provision of safety-critical patient information to paramedics

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First reported 28 Feb 2014•Latest report 28 Apr 2023

Definition

What this concern includes

Includes failures in the bounded process of preparing, maintaining or communicating safety-critical patient information to attending paramedics or ambulance crews, including missing or inaccurate medical history, allergies, medication, mobility, consciousness, presenting circumstances or other information needed for pre-hospital assessment and treatment.

Not included

  • Excludes failures in ambulance computer systems or ambulance-service information-transfer systems where the source does not identify the patient-information handover or provision process as deficient.
  • Excludes generic clinical record-keeping, inter-service communication or handover failures where paramedics or ambulance crews are not the relevant recipient.
  • Excludes failures limited to paramedic clinical judgement, treatment, transport, dispatch or hospital handover after the relevant patient information was reliably provided.
  • Excludes information deficiencies concerning non-safety-critical administrative details unless they materially impair paramedic assessment or treatment.
Reports
12

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
18

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.

East of England Ambulance Service NHS Trust2
Essex Partnership University NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Department of Health and Social Care1
Essex Police1
Magenta Living Support Link1
Metropolitan Police Service1
Mildmay Medical Practice1
National Institute for Health and Care Excellence1
North East London NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Pennine Care NHS Foundation Trust1
PJ Care Limited1
Rush Court1
Shaw Healthcare Limited1

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. Inner North London

    AI-generated summary

    Rita Paton · 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 Paton, who had type 2 diabetes, hypertension, chronic kidney disease and dementia, died on 8 December 2014 from ischaemic and hypertensive heart disease, contributed to by chronic kidney disease and diabetes mellitus. Concerns included the lack of a system to ensure requested blood tests were completed and reported, the absence of a clear process for involving family when a patient lacks capacity to make decisions about appointments, and limited access to patients’ medical and medication information for attending medical crews.

    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

    Unavailability of patients’ past medical and medication history to attending medical crews

    Wider context from the report

    “(3) The lack of information available to the attending medical crews on 7 December 2014 was also a concern of Mrs Paton’s family, which I share. I heard evidence from the attending Paramedic that there is rarely such information available but that it can be of vital importance when undertaking assessments. There was no evidence that, had information regarding Mrs Paton’s past medical and medication history been available, the outcome would have been different. However, I am concerned that such circumstances will exist and that the risk of non-availability of this information should be addressed. ”

    Source location

    Rita Paton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Oxfordshire

    AI-generated summary

    Peter Norman Nott · 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

    Peter Norman Nott, who had Parkinson's disease and was at very high risk of falls, experienced an unwitnessed fall at a nursing home on 2 September 2013 and died on 8 September 2013 from a subdural haemorrhage and Parkinson's disease. The concerns included that neurological observations after the fall were not undertaken beyond a simple visual examination and that inaccurate information about his consciousness was passed to paramedics.

    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 accurately communicate a patient's level of consciousness to attending paramedics

    Wider context from the report

    “The doctor’s conclusion that Dr Norman Nott had been unconscious was information obtained from the paramedics attending at the nursing home who had gleaned the information that he was unconscious from the staff. The evidence that Dr Norman Nott was unconscious was incorrect. This information should have been passed on accurately. ”

    Source location

    Peter Norman Nott · 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

    Review procedures governing information provided to paramedics attending the home.

    Verbatim wording from the response

    “Procedures have been reviewed with reference to information given to paramedics attending the home. The procedure states that only a Registered Nurse or person in charge of the home must hand over clinical information to the paramedic team. This is to be clear and concise, detailing observations and clinical judgement where appropriate. This will then be recorded clearly in the resident’s care plan for future”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 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

    Implement and disseminate requirements for registered nurses or persons in charge to provide concise clinical handovers, record them in care plans, and obtain staff acknowledgement.

    Verbatim wording from the response

    “Procedures have been reviewed with reference to information given to paramedics attending the home. The procedure states that only a Registered Nurse or person in charge of the home must hand over clinical information to the paramedic team. This is to be clear and concise, detailing observations and clinical judgement where appropriate. This will then be recorded clearly in the resident’s care plan for future”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    Open published response
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Data last updated 7 September 2026