19 Dec 2023 Margaret Ann Waylett · Prevention of Future Deaths report East London
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Concerns raised 1
Dangerously inadequate junior orthopaedic staffing levels View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Margaret Ann Waylett · 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
Margaret Ann Waylett underwent surgery for a humerus fracture and developed ongoing low blood pressure and intermittent oxygen requirements. She later suffered a cardiac arrest and died in hospital after, according to the report, necessary medical intervention was not provided. Concerns included failures to provide medical reviews, lack of access to NEWS charts and confusion about responsibility for her care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Dangerously inadequate junior orthopaedic staffing levels
Wider context from the report “(1) The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous” .
” Source location Margaret Ann Waylett · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Senior doctors consider staffing levels appropriate, disputing that junior orthopaedic staffing levels were dangerous.
Verbatim wording from the response “1. Concern: The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”.” Source location Response from Barts Health NHS Trust
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Concerns raised 1
Failure to maintain sufficient staffing and funding capacity for timely surgery View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England University Hospitals of North Midlands NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Increase urgent and emergency care capacity, including funding additional capacity and 5,000 new beds.
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NHS England
Train, retain and reform the NHS workforce through the Long Term Workforce Plan.
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NHS England
Increase elective care capacity, prioritise diagnosis and treatment, transform care delivery, and improve patient information and support.
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NHS England
Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.
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University Hospitals of North Midlands NHS Trust
Operate a dedicated fragility-fracture theatre list five days per week.
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Mrs Kathleen Booth · Prevention of Future Deaths report
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Report summary
Mrs Kathleen Booth was admitted to hospital after a fall in her garden on 9 June 2023, sustaining a fractured neck of femur. Surgery was delayed for four days and, after the operation, she deteriorated suddenly and died. The concerns included staffing and funding pressures, limited weekend cover, and the potential disadvantage to patients injured on a Friday.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain sufficient staffing and funding capacity for timely surgery
Wider context from the report “1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding ; and wards having to undertake elective and emergency work at the same time . Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available.
” Source location Mrs Kathleen Booth · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase urgent and emergency care capacity, including funding additional capacity and 5,000 new beds.
Verbatim wording from the response “In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train, retain and reform the NHS workforce through the Long Term Workforce Plan.
Verbatim wording from the response “In June 2023, NHS England also published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase elective care capacity, prioritise diagnosis and treatment, transform care delivery, and improve patient information and support.
Verbatim wording from the response “Elective care recovery also continues to be a priority for the NHS. In February 2023 the Delivery plan for tackling the Covid-19 backlog of elective care was published by NHS England. This focused on four areas of delivery to increase health service capacity, prioritise diagnosis and treatment, transform how we provide elective care and provide better information and support to patients. This is supported by a government spend of more than £8 billion between 2022/23 and 2024/25, including a £5.9 billion capital investment in new beds, equipment, and technology. Further priorities were set out in a letter to NHS acute Trusts in May 2023, which can be found here: NHS England » Elective care 2023/24 priorities.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a dedicated fragility-fracture theatre list five days per week.
Verbatim wording from the response “However, the trust does annually review capacity and demand for all its services and based on one of these reviews and subsequent business case, on the 6 November 2023, the Trauma Directorate introduced a dedicated fragility fracture list, 5 days per week. This has seen a reduction in time to theatre for this cohort of patients since its inception. Capacity and demand also include the weekend provision and the division are preparing a business case to see if the demand over the weekend period requires the same on a Saturday also.” Source location Response from University Hospitals of North Midlands NHS Trust
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Concerns raised 1
Insufficient nursing and clinical staffing capacity View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Philip Hawkins · 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 Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient nursing and clinical staffing capacity
Wider context from the report “Staffing
9. There were insufficient nursing and clinical staff to attend to the numbers of patients as outstanding nursing shifts went unfulfilled on the nursing rota .
10. Due to the presenting circumstances, staff were unable to fulfil their role in caring for Mr Hawkins.
11. Specifically, I am concerned as to the wait and delay Mr Hawkins had to endure to enter hospital and the same in respect of being provided with a bed; the inability of staff to tend to him; the lack of available staff and the lack of written record of assessment and treatment.
” Source location Philip Hawkins · Prevention of Future Deaths report
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Concerns raised 1
Insufficient nursing staffing capacity and resilience in the community mental health team View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Benjamin James HART · 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
Benjamin Hart, aged 25, died by hanging at his mother’s home after contacting the Crisis team three times in the preceding two days and expressing hopelessness and suicidal feelings. The report describes limited contact with the community mental health team, a breakdown in his care-coordinator relationship, and no attempted contact before his death despite the team being notified. A principal concern was severe nursing-staff shortages, which left no capacity to allocate him a replacement care coordinator.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient nursing staffing capacity and resilience in the community mental health team
Wider context from the report “The Trust had a shortfall of nursing staff in the Dover and Deal area at the time that Benjamin Hart was under the community mental health team such that although 16 nurses were required to run the service, the Trust only had 8 nurses employed at the time, 2 of whom were long term sick . This left a working complement of 6 nurses to cover the whole area, which required them to take on additional duties . There was no resilience within the team and therefore when the relationship between Ben and his care coordinator broke down there was no capacity within the team to allocate him another care coordinator .
Although the Trust has regrouped, reorganised and there has been some limited recruitment the shortfall endures ; the evidence given at the inquest being that this is a national issue but it is particularly difficult to recruit within this area of Kent
” Source location Benjamin James HART · Prevention of Future Deaths report
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9 Jun 2022 Shirley Alice Moloney · Prevention of Future Deaths report East London
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Concerns raised 1
Insufficient availability of mental health nurses in care homes and nursing homes View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Shirley Alice Moloney · 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
Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of mental health nurses in care homes and nursing homes
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses . They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” Source location Shirley Alice Moloney · Prevention of Future Deaths report
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Concerns raised 1
Unavailability of separate designated nurse coverage for consecutive days View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Julie Elizabeth Nolan · 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
Julie Elizabeth Nolan had underlying diabetes, hypertension, chronic kidney disease and peripheral vascular disease, and was admitted to a care home with existing pressure damage to her left foot. She later developed further pressure damage and acute osteomyelitis, deteriorated with breathing difficulties and low oxygen saturations, and died in hospital on 30 January 2022. Concerns included limited documentation of wound management and pressure care, uncertainty about whether care plans were followed, and the Manager and Registered Nurse being the designated nurse for two consecutive days.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of separate designated nurse coverage for consecutive days
Wider context from the report “2. I am concerned that the Manager and Registered Nurse was the designated nurse for the Care Home for two consecutive days .
” Source location Julie Elizabeth Nolan · Prevention of Future Deaths report
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27 Jan 2022 Maria Howell · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of qualified nursing staff to reinsert time-critical RIG tubes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Maria Howell · 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
Maria Howell, a resident of Cranham Court Nursing Home, died in hospital on 28 September 2019 after her RIG tube fell out, reinsertion was delayed, and she later developed peritonitis. The concerns were that the care home lacked qualified nursing staff to reinsert a time-critical RIG tube and that staff did not recognise the need for urgent medical attention when she became critically ill.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of qualified nursing staff to reinsert time-critical RIG tubes
Wider context from the report “That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical . That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention.
” Source location Maria Howell · Prevention of Future Deaths report
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3 Nov 2021 Angela Margaret O’Donnell · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Shortage of nursing staff View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Frimley Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Frimley Health NHS Foundation Trust
Continue targeted and general recruitment campaigns to increase the substantive nursing workforce.
View source
Frimley Health NHS Foundation Trust
Increase student placement capacity to expand the future nursing workforce.
View source
Frimley Health NHS Foundation Trust
Provide trainee nursing associate and degree apprenticeship routes to develop nursing staff.
View source
Frimley Health NHS Foundation Trust
Continue international nurse recruitment and provide recruited nurses with examination preparation, registration support and preceptorship.
View source
Frimley Health NHS Foundation Trust
Continue recruiting healthcare support workers through recruitment drives, apprenticeships and Care Certificate training.
View source
Frimley Health NHS Foundation Trust
Encourage substantive and former permanent staff to undertake shifts through the Trust’s staff bank.
View source
Frimley Health NHS Foundation Trust
Recruit a Trust People Promise Manager to support workforce retention and wellbeing.
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Angela Margaret O’Donnell · 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
Angela Margaret O’Donnell, who had advanced lung cancer, was admitted to hospital with confusion and pain and died in hospital on 14 January 2020. The report identifies incomplete NEWS charting and missed opportunities to escalate her deteriorating condition, while stating that this was not found to have caused her death. The principal concern was reliance on agency nurses, who may not receive the trust’s refresher training and related communications, in the context of wider nursing staff shortages.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Shortage of nursing staff
Wider context from the report “(2) What plans are there nationally to reduce the shortage of nursing staff going forward ? This question is for the Secretary of State.
” Source location Angela Margaret O’Donnell · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue targeted and general recruitment campaigns to increase the substantive nursing workforce.
Verbatim wording from the response “I will explain how we are aiming to reduce our reliance on agency nursing staff by:” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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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 Increase student placement capacity to expand the future nursing workforce.
Verbatim wording from the response “We also look to increase our student placement capacity year on year to increase the number of nursing staff in training. It is intended aim that these nurses will then continue in substantive roles within the Trust upon qualification.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide trainee nursing associate and degree apprenticeship routes to develop nursing staff.
Verbatim wording from the response “We offer various training routes into registered nursing through Trainee Nursing Associate (TNA) and Degree Apprenticeship routes. Over the last few years we have successfully supported 50 Care Assistants through their Nursing Associate (NA) training and currently have a further 57 staff on their TNA programme. These programmes have continued to grow each year and it is hoped that this will help stabilise our substantive nursing workforce over the next three years and reduce our reliance on temporary staffing.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue international nurse recruitment and provide recruited nurses with examination preparation, registration support and preceptorship.
Verbatim wording from the response “International recruitment forms a large part of our nursing recruitment activity, with 172 international nurses recruited in 2019/20 and around 200 so far in 2020/21. We have an ambition to increase our international nurse recruitment to around 400 nurses throughout 2022, with additional funding from NHSE/I to support this.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting healthcare support workers through recruitment drives, apprenticeships and Care Certificate training.
Verbatim wording from the response “Our registered nursing workforce is also supported by healthcare support workers. The Trust regularly undertakes recruitment drives to meet the national target of zero healthcare support worker vacancies. This is again supported by offering additional training through apprenticeship routes and the Care Certificate, with additional funding currently being provided by NHSE/I to support this initiative. 209 care assistants have started in the Trust over the last 12 months with a further 93 having been recruited who are currently completing their pre-employment checks.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage substantive and former permanent staff to undertake shifts through the Trust’s staff bank.
Verbatim wording from the response “2. Encouraging our substantive staff to undertake bank shifts and increasing the number of ‘bank nurses’ we employ” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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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 Recruit a Trust People Promise Manager to support workforce retention and wellbeing.
Verbatim wording from the response “The Trust recognises the importance of retaining staff as well as recruitment, this is vital to achieving a safe and sustainable workforce. We understand that retention of nursing staff is a recognised challenge nationally and we are working hard to improve staff wellbeing as a cornerstone of this issue.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust will not address or comment on the national nursing shortage because that issue falls outside this response’s remit.
Verbatim wording from the response “I recognise the point you have made about the reliance on agency staffing being a national issue for the NHS and that you have also directed your concerns to the Secretary of State for Health. It would not be appropriate for me to seek to address or comment on the national issue in this response, but I hope to set out what Frimley Health NHS Foundation Trust is doing to address your first concern listed above.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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1 Sep 2021 Hazel Fleur Wiltshire · Prevention of Future Deaths report South London
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Concerns raised 1
Inadequate staffing levels for patients with higher dependency needs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Hazel Fleur Wiltshire · 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
Hazel Fleur Wiltshire was admitted to hospital after a fall at home and died there on 19 February 2021 from pneumonia caused by the fall and Covid-19 acquired in hospital. Concerns included lengthy delays in responding to call bells, inadequate staffing and the absence of falls risk assessments across three wards.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate staffing levels for patients with higher dependency needs
Wider context from the report “(2) Staffing levels were inadequate due to higher dependency of patients with Covid . I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs . Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell . The family could hear other patients on the ward crying out for help.
” Source location Hazel Fleur Wiltshire · Prevention of Future Deaths report
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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 Increase recruitment and retention activity to attract, develop and retain the nursing workforce.
Verbatim wording from the response “Throughout the waves of COVID-19 our recruitment and retention activity did continue although since wave 2 we have increased this work which is happening alongside HR colleagues across all sites to ensure we have robust plans to attract, develop and retain our current and future workforce.” Source location Response from Princess Royal University Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily senior-led staffing calls to mitigate staffing risks and maintain safe patient-to-staff ratios.
Verbatim wording from the response “A review of staffing rates at the PRUH in January shows that the average fill rate for day staff was 86.7% (the lowest rate recorded for day staffing at the PRUH site in the last 12 months) and the average fill rate for night staff was 91.6% (also the lowest rate recorded for night staffing at the PRUH site in the last 12 months). Although we experienced more stretched nurse to patient ratios during the pandemic as we were in extremis I want to provide assurance that daily staffing calls took place, led by senior nursing staff at the PRUH/SS, to mitigate risks and ensure ratios were as safe as possible.” Source location Response from Princess Royal University Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide proactive continence care, including scheduled assistance to the bathroom.
Verbatim wording from the response “We recognise that falls in hospital are often connected with patients using the bathroom or trying to get to the bathroom. We are working to ensure that our continence care is pro-active, e.g. patients assisted to the bathroom before they go to sleep and early in the morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse Specialist Teams are currently working collaboratively to share learnings from poor practice, like you describe, in order to raise awareness and show case best practice. We are ensuring, in line with our Trust wide competency matrix and training needs analysis, that our senior nurses and practice development nurses have the appropriate skills and knowledge to provide gold standard continence care to all our patients and will role model this at all times.” Source location Response from Princess Royal University Hospital
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28 May 2021 Peggy COPEMAN · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Insufficient CPR-trained staffing for patient transport View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Peggy COPEMAN · 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
Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient CPR-trained staffing for patient transport
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” Source location Peggy COPEMAN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.
Verbatim wording from the response “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an authorised internal training capacity by qualifying a staff member to train others within the company.
Verbatim wording from the response “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.