Recurring concern

Unreliable provision of safety-critical patient information to paramedics

First to latest report 28 Feb 2014 — 28 Apr 2023

Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
18

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.

What is 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 and published responses 12 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, 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 provide paramedics with a clear and relevant patient history

    Wider context from the report

    “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”

    Source location

    Winbourne Gregory Charles · 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

    Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.

    Verbatim wording from the response

    “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 4 · response
    Published 5 May 2023

    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

    SBARD and the Adult Cardiac Checklist already provide recognised frameworks for handing cardiac incident information to paramedics.

    Verbatim wording from the response

    “g. Staff could or would not provide clear and relevant history to paramedics.”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 6 · response
    Published 5 May 2023

    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 care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  2. Essex

    AI-generated summary

    Sharon Elizabeth Langley · 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

    Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

    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

    Delays in calling emergency services and relaying basic emergency information

    Wider context from the report

    “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”

    Source location

    Sharon Elizabeth Langley · 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

    Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.

    Verbatim wording from the response

    “- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 7 March 2023

    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

    Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.

    Verbatim wording from the response

    “- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    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

    Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.

    Verbatim wording from the response

    “- The Head of Deteriorating Patient Pathways and Resuscitation Training Officer, operational colleagues and the Lessons Team are formulating a communication tool for use when contacting the East of England Ambulance Service. EPUT Subject Matter Experts have liaised with external partner colleagues to devise the tool and the specific information which our colleagues will require in emergency scenarios. The questions the Ambulance control room will ask when reporting an emergency have been used as the basis for the communication tool poster. It will include essential information relating to the patients presenting medical condition, as well as site information including address and postcode. This aide memoir poster will be positioned adjacent to the Nurses Station and a laminated copy placed inside the grab bag. This is due to be completed and launched across all wards in May 2023 (1b).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    Open published response

  3. Inner North London

    AI-generated summary

    Agnès Blandine Marthe MARCHESSOU · 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

    Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

    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 pass relevant incident and vulnerability information to ambulance and hospital staff

    Wider context from the report

    “The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital. 2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children. The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses. ”

    Source location

    Agnès Blandine Marthe MARCHESSOU · 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

    Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.

    Verbatim wording from the response

    “Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms Marchessou in the ambulance. This would be normal practice where two parties were involved, with each officer initially dealing with their casualty, witness or other party involved. The senior officer has discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the decisions he made. It was evident from their discussion that the officer was reflective as he recognised that he would deal with a similar incident differently next time. He would now relay the bus driver’s account to his colleague who was dealing with Ms Marchessou at the scene and subsequently provide this information to the medical staff at the scene and at the hospital.”

    Source location

    2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
    Page 2 · response
    Published 30 December 2020

    Open published response

  4. Essex

    AI-generated summary

    Sharon Louise Kelly · 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

    Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

    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 sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments

    Wider context from the report

    “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019) ”

    Source location

    Sharon Louise Kelly · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester North

    AI-generated summary

    Muhammed Saif Abdul Haleem · 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

    Muhammed Saif Abdul Haleem was 13 years old and had a severe, life-limiting neurological condition. He became unresponsive at home on 8 December 2018, was found in asystole, and died after resuscitation efforts were terminated; the principal concern was that an outdated DNA-CPR document had remained on the emergency service system for seven years without the knowledge or support of the clinicians involved in his care.

    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 maintain current information for immediate guidance to paramedics

    Wider context from the report

    “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are ”

    Source location

    Muhammed Saif Abdul Haleem · 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

    Place alerts on the NWAS system for children with current advance care plans and review them when changed or at least annually.

    Verbatim wording from the response

    “I can confirm that alerts have now been placed on the NWAS system for all children who have current advance care plans (ACP) - these alerts will be reviewed if any changes are made or as a minimum once per year when the ACP is reviewed. In addition, we will review archived patient notes/records for any children with palliative care needs known to the Children’s Community Nursing Team (CCNT) on 15/11/19 to ensure that any ACP’s that may have commenced before the electronic system was set up are included.”

    Source location

    2019-0316-Response-by-Pennine-Care-NHS-Trust
    Page 1 · response
    Published 6 November 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

    Review archived records for children with palliative care needs to identify advance care plans predating the electronic system and include them in alerts.

    Verbatim wording from the response

    “I can confirm that alerts have now been placed on the NWAS system for all children who have current advance care plans (ACP) - these alerts will be reviewed if any changes are made or as a minimum once per year when the ACP is reviewed. In addition, we will review archived patient notes/records for any children with palliative care needs known to the Children’s Community Nursing Team (CCNT) on 15/11/19 to ensure that any ACP’s that may have commenced before the electronic system was set up are included.”

    Source location

    2019-0316-Response-by-Pennine-Care-NHS-Trust
    Page 1 · response
    Published 6 November 2019

    Open published response

  6. West Sussex

    AI-generated summary

    James William Francis · 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

    James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly 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 provide paramedics with basic patient information

    Wider context from the report

    “They reported that they found Mr Francis on the floor leaning up against the dining room chair and over to his right side. They accepted that they were assertive but felt this was born from a frustration to find a time critical patient in such a position and staff were unable to answer basic questions about past medical history, allergies, mobility, communications for current medication. ”

    Source location

    James William Francis · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the adapted Hospital Passport Transport Traffic Light System across West Sussex homes and the wider company.

    Verbatim wording from the response

    “I also note that paramedic referred to the Hospital Passport. We have adapted the Hospital Passport - Transport Traffic Light System within all our West Sussex care homes initially and through the wider company. This is to provide the paramedic and hospital staff the most helpful information that isn't only about illness and health. This accompanies the Service User to inform and support. It is implemented within our Care Plan systems.”

    Source location

    2019-0202-Response-by-Shaw-Healthcare
    Page 3 · response
    Published 23 August 2019

    Open published response

  7. Norfolk

    AI-generated summary

    Christopher Williams · 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 Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.

    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 communicate arranged admission-bed information to ambulance crews

    Wider context from the report

    “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines. (2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm. (3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis. The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk. In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant. It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be addressed. ”

    Source location

    Christopher Williams · 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

    Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.

    Verbatim wording from the response

    “In the initial call the HCP called and asked for the patient to be conveyed to the Norfolk and Norwich University Hospital, the clinician requested for the patient to be taken to the Emergency Assessment Unit. When we received a 999 call from the property identifying that the patient’s condition had deteriorated the dispatcher allocated on the new call as it was of a higher priority, in line with 20180525 Ambulance System Indicators. Due to the dispatcher assigning to the new call it is apparent that information pertaining to the destination of the patient was omitted as the information is sent to the crew using data. We are in communications with the CAD supplier to make an alteration to the duplication process which would allow pertinent information to be transferred from the original call into the call which EEAST are “running on”.”

    Source location

    2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 14 August 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

    Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.

    Verbatim wording from the response

    “Having a technical solution will minimise risk of human error. As an interim arrangement we will ask all dispatch staff to ensure that any pertinent information of this kind is transferred into the new call, until there is a technological resolution in place.”

    Source location

    2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 14 August 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

    Share CAD information-recording and transmission best practice and solutions with other ambulance services.

    Verbatim wording from the response

    “We are also working with our colleagues in other Ambulance Services who use the same CAD to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources.”

    Source location

    2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 14 August 2019

    Open published response

  8. Milton Keynes

    AI-generated summary

    Philip David Ashton · 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

    Philip David Ashton, a resident of Mallard House, was administered warfarin in error on 13, 14 and 15 October 2017. He was found bleeding from an arteriovenous graft on 17 October, and the report raised concerns about the medication error, the lack of an emergency response and the unavailability of his medical information to ambulance staff; he later died in hospital.

    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 staff with medical history and medication information

    Wider context from the report

    “(3) The ambulance staff were not given any information about the deceased as to his medical history or medication. The notes relating to the deceased should have been available to them. ”

    Source location

    Philip David Ashton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Luke Christie AYRES · 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

    Luke Christie AYRES, aged 24, died on 27 September 2015 while serving a custodial sentence as an inpatient at Raeside Clinic. He was found hanging by a ligature in his bedroom and could not be resuscitated. Concerns included delays and communication risks in contacting the ambulance service, and the absence of staff to escort paramedics from reception to the ward.

    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 the Ambulance Service with accurate current patient-status information

    Wider context from the report

    “1. The 999 call to the ambulance service made by Raeside reception after the issuing of a 2222 medical emergency call was cut off when they attempted to transfer the Ambulance Service to Ward Severn. The ambulance Service therefore had to get the number from the operator and called back a minute later. When they were put through to the Ward the person they were speaking with was not at Luke’s side and did not know his current status because she was in an office some distance away from him and the staff with him. There is no evidence that this actually had an impact on Luke’s death but there are risks for the future arising from the fact that: a) the Ward staff do not call 999 themselves necessitating a delay and a risk of the call being cut off when the call is transferred to the Ward; and b) the person providing information to the Ambulance Service may not know the patient’s current status and could therefore give incorrect information. ”

    Source location

    Luke Christie AYRES · 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

    Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.

    Verbatim wording from the response

    “We have therefore decided to extend the simulation of medical emergencies on our wards at Reaside to include the connection of the call to the ambulance service and to also ensure that the individual nominated to make the call has all of the relevant medical information and observations of the patient to hand. We currently deliver quarterly medical emergency simulation exercises at Reaside Clinic (the most recent being just 2 weeks ago) and will explore the possibility of increasing the frequency.”

    Source location

    2016-0148-Response-by-Birmingham-and-Solihull-NHS-Trust
    Page 2 · response
    Published 15 April 2016

    Open published response

  10. Liverpool and the Wirral

    AI-generated summary

    Ronald VOLANTE · 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

    Ronald Volante, who had ischaemic heart disease and an enlarged heart, called an out-of-hours alarm monitoring service for help on 5 November 2015. An ambulance was called, but information about his cardiac history was not passed on, and the service did not report a change in his condition when he stopped responding; he was found deceased when the ambulance arrived. The concerns focused on call-handler training, use of medical history, and communicating changes in circumstances to emergency services.

    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 use available medical history to advise ambulance services of cardiac problems

    Wider context from the report

    “(1) Magenta Living Support Link had access to Mr Volante’s medical history and there is no evidence that this was used to advise the ambulance service of his cardiac problems – is this covered in the induction training of call handlers? ”

    Source location

    Ronald VOLANTE · 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

    Require call handlers to share relevant medical details with emergency services at initial contact unless instructed otherwise.

    Verbatim wording from the response

    “Following the concerns raised at the inquest and subsequently detailed in the Regulation 28 Report to Prevent Further Deaths Notice we have revised how we will deal with calls to the Ambulance service. We have written to all of our community alarm customers, including those organisations with whom we have contracts to provide a similar service. We have confirmed that with immediate effect that there will be an addition to current procedures in”

    Source location

    2016-0499-Response-by-Magenta-Living
    Page 1 · response
    Published 28 January 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Brief all trained community alarm call handlers on the revised procedures, record their understanding, and provide the updated procedure.

    Verbatim wording from the response

    “As a result of this change of procedure, all Magenta Living community alarmed trained call handlers were briefed with effect from 28ᵗʰ January 2016 as to this change and provided with a copy of the updated procedure that now includes this additional stage. As part of this discussion, staff confirmed their understanding of the new procedure which is recorded in their training record. This change of procedure will also be addressed with any new staff as part of their normal induction programme.”

    Source location

    2016-0499-Response-by-Magenta-Living
    Page 2 · response
    Published 28 January 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Address the revised procedures with new call-handling staff through the normal induction programme.

    Verbatim wording from the response

    “As a result of this change of procedure, all Magenta Living community alarmed trained call handlers were briefed with effect from 28ᵗʰ January 2016 as to this change and provided with a copy of the updated procedure that now includes this additional stage. As part of this discussion, staff confirmed their understanding of the new procedure which is recorded in their training record. This change of procedure will also be addressed with any new staff as part of their normal induction programme.”

    Source location

    2016-0499-Response-by-Magenta-Living
    Page 2 · response
    Published 28 January 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor staff implementation of procedural changes through spot audits, call-recording reviews, data checks, and performance improvement measures.

    Verbatim wording from the response

    “However, in light of the Coroner’s concerns and appreciating that standards can always be improved, Magenta Living has incorporated a number of additions to the procedures manual as a result of the Coroner’s recommendations as set out above. Our standard practice, which has been followed in respect of these changes, is that any changes or amendments made to procedures are always quickly communicated to staff across the various shifts. This is carried out on a one-to-one basis and also at team level. For assurance purposes, Team Leaders and managers ensure staff implement any changes smoothly and effectively and measures are put in place to monitor this such as spot auditing, listening to call recordings, data checks. Any concerns are immediately brought to the attention of the member of staff and a performance improvement plan is established.”

    Source location

    2016-0499-Response-by-Magenta-Living
    Page 3 · response
    Published 28 January 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026