Recurring concern

Unreliable CAD systems for safety-critical information

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First reported 18 Jan 2018•Latest report 10 Mar 2026

Definition

What this concern includes

Includes failures of explicitly identified computer-aided dispatch systems across emergency services where CAD information is incomplete, inaccurate, outdated, inaccessible or not reliably communicated for risk assessment, location, triage, dispatch or response decisions.

Not included

  • Excludes generic emergency call-handling or dispatch-capacity failures where no CAD-system deficiency is identified.
  • Excludes clinical or operational information-system failures not explicitly involving a computer-aided dispatch system.
  • Excludes failures limited to staff training, communication or record keeping unless they directly impair the safety-critical operation or information reliability of a CAD system.
  • Excludes downstream emergency response or treatment failures where the relevant CAD information was reliable and available.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2018–2026

First to latest report issue date

Stated actions
12

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2
East Midlands Ambulance Service NHS Trust1
NEMS Community Benefit Services Limited1
NHS Nottingham and Nottinghamshire Integrated Care Board1
Ordnance Survey1
Recipient name withheld1
South East Coast Ambulance Service NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1
Sussex Police1

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. Bedfordshire and Luton

    AI-generated summary

    Darryl JOHNSON · 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

    Darryl JOHNSON was found deceased at home on 24 February 2025 after failing to attend work. Earlier that day, he had called ambulance services with breathing problems and feeling faint, but the crew was directed to a different address because of an address and map database error. The principal concern was why the database lacked full details of his property despite his having purchased it and paid Council Tax there for over 11 years; it remained unclear whether attending the correct address would have avoided his death.

    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 accurate and up-to-date CAD address and map data

    Wider context from the report

    “The East of England Ambulance Services Trust confirmed that their CAD system utilises an address and map database supplied by Ordnance Survey but that postal addresses listed in this database along with mapping coordinates to locate the property are not always accurate. Whilst it is accepted that it is not feasible for the database to be 100% accurate and up to date because it will take time for the system to be updated (as for example in the following situations: • New builds • Change of property name/number • Change of use for a property/dwelling) The Deceased had purchased his property over 11 years ago and had been paying Council Tax since that time. It is, therefore, of concern why the database still did not have full details of his address. ”

    Source location

    Darryl JOHNSON · 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

    Include unmatched Royal Mail address data in NGD Address V3.

    Verbatim wording from the response

    “Before I set out a summary of the actions Ordnance Survey is taking in response to the matters of concern, it is notable that the latest version of our most recent Address product - NGD Address Version 3 (‘NGD Address V3’) which was released in October 2025 - already includes unmatched Royal Mail address data, including 27B, in the 'Royal Mail Address' feature type. Since 27B remains unmatched with any Central Bedfordshire Council LLPG record, the product only includes the address of 27B and an estimated position at the beginning of Market Square, rather than assigning geographic co-ordinates to the specific building to which 27B relates.”

    Source location

    Response Ordnance Survey
    Page 3 · response
    Published 18 March 2026

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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

    Analyse unmatched address records across England and Wales and prioritise them for resolution by local authorities.

    Verbatim wording from the response

    “1. Ordnance Survey and GeoPlace will undertake a comprehensive analysis of unmatched address records across England and Wales, and will use the results of the analysis to prioritise unmatched records for resolution by individual local authorities.”

    Source location

    Response Ordnance Survey
    Page 4 · response
    Published 18 March 2026

    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

    Work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B.

    Verbatim wording from the response

    “2. As part of this, Ordnance Survey and GeoPlace will work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B.”

    Source location

    Response Ordnance Survey
    Page 4 · response
    Published 18 March 2026

    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

    Promote Emergency Services’ and Licensed Partners’ adoption and use of NGD Address V3.

    Verbatim wording from the response

    “1. We will promote the adoption and use by the Emergency Services (and by our Licensed Partners who include Ordnance Survey data within their products and services and work with the Emergency Services) of NGD Address V3, which as noted above, includes Royal Mail addresses such as 27B which have not been matched.”

    Source location

    Response Ordnance Survey
    Page 4 · response
    Published 18 March 2026

    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

    Local authorities are responsible for maintaining authoritative address registers, and resolving unmatched addresses depends on their cooperation and engagement.

    Verbatim wording from the response

    “- At the time of the incident, Ordnance Survey’s address products only included addresses that had been verified through an address matching process with the relevant local authority (see further details in Schedule 1). This is because local authorities have statutory responsibility for street naming and numbering and maintaining address information in the official register of addresses known as the Local Land and Property Gazetteer ('LLPG'). The local authority is therefore considered to be the authoritative source of the address.”

    Source location

    Response Ordnance Survey
    Page 2 · response
    Published 18 March 2026

    Open published response
  2. Nottinghamshire

    AI-generated summary

    Adam Ali Hussain · 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

    Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information

    Wider context from the report

    “2. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS. ”

    Source location

    Adam Ali Hussain · 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 transferred EMAS cases and monthly UCCH highlights, escalating risks through joint governance structures.

    Verbatim wording from the response

    “Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or automated ITK pathways. These pathways present lower risk because they are generated through NHS Pathways and meet defined criteria, and no further sepsis-related patient safety incidents have been identified since pathway changes in June 2025. Since 27th June 2025, NEMS implemented a pause on manually pushed calls while improvements were agreed with EMAS. Although manual pushes resumed on 21st July following assurance regarding CAD note quality and governance arrangement, NEMS confirms that it has not continued with manually pushed calls since 3rd December 2025.NEMS continues to proactively review cases transferred from EMAS and escalate concerns through joint governance structures, alongside close monitoring of monthly UCCH highlight reports to identify emerging themes”

    Source location

    Response from Nottingham Emergency Medical Service
    Page 2 · response
    Published 8 January 2026

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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

    Improve CAD-to-Adastra transfer formatting, structure, legibility and visibility of prior clinical validation through ongoing technical engagement.

    Verbatim wording from the response

    “NEMS has engaged in ongoing discussions with EMAS and OneAdvanced, the software provider responsible for Adastra (the electronic patient record system used by NEMS) to improve the formatting, structure and clarity of CAD-to-Adastra transfers. This has included identifying the duplication arising from the multiple message structure and formally requesting technical solutions to improve legibility and presentation of narrative information.”

    Source location

    Response from Nottingham Emergency Medical Service
    Page 3 · response
    Published 8 January 2026

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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

    Implement BaRS in Adastra and progress migration from the legacy ITK framework with partner organisations and required system configuration.

    Verbatim wording from the response

    “In addition, this process has generated learning and further improvement work between DHU 111 and NEMS in relation to the direct transfer of information from the 111 provider into NEMS systems will improve clinical safety for all patients. NEMS confirms that it has formally agreed with OneAdvanced to implement the Booking and Referral Standard (BaRS) within Adastra and is progressing this work in partnership with DHU. Following system configuration, a formal multi-agency project involving NEMS, DHU, OneAdvanced, NHIS and the ICB Directory of Services team will oversee the migration of CAS and Out of Hours profiles from the legacy ITK framework to BARS, alongside necessary system configuration to ensure structured, complete and clearly displayed clinical information transfer.”

    Source location

    Response from Nottingham Emergency Medical Service
    Page 3 · response
    Published 8 January 2026

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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

    Review whether internal risk flags are needed when duplicated or poorly formatted transferred information obscures clinical clarity.

    Verbatim wording from the response

    “• Review whether additional internal NEMS risk flags should be applied where duplication or poor formatting obscures clinical clarity.”

    Source location

    Response from Nottingham Emergency Medical Service
    Page 4 · response
    Published 8 January 2026

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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

    Require clinicians to review available information and make all Category 3 transfers through a clinical-only process, ending manual pushes to NEMS.

    Verbatim wording from the response

    “Historically, non-clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, EMAS implemented a significant change to operational practice:”

    Source location

    Response from East Midlands Ambulance Service NHS Trust
    Page 3 · response
    Published 8 January 2026

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    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 other than concern three are better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board.

    Verbatim wording from the response

    “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 8 January 2026

    Open published response
  3. Surrey

    AI-generated summary

    Josephine Celia 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

    Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

    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 keep continuous CAD records updated with changing patient information

    Wider context from the report

    “13. The continuous CAD was not kept updated with details of Jo’s condition or other useful information when each of the calls came in. ”

    Source location

    Josephine Celia BARKER · Prevention of Future Deaths report
    Page 9 · concerns

    Open source report
  4. West Sussex

    AI-generated summary

    Paul Lawrence Hanton · 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

    Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.

    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 clearly record the initial risk assessment in the CAD

    Wider context from the report

    “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces. ”

    Source location

    Paul Lawrence Hanton · Prevention of Future Deaths report
    Page 4 · 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

    Maintain and apply new missing-person call-handling guidance requiring clear recording of risk levels in incident logs.

    Verbatim wording from the response

    “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 1 · response
    Published 14 March 2018

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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

    Deliver scenario-based training to contact handlers and controllers on recording missing-person incidents under the new process.

    Verbatim wording from the response

    “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 1 · response
    Published 14 March 2018

    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 duty inspectors with continuing professional development on managing threat, harm and risk and documenting decisions clearly in incident logs.

    Verbatim wording from the response

    “This included scenario based exercises and was delivered over a 12 week training cycle between January and March 2017 prior to the new process being invoked in May. It was further audited in June before the policy went live in September 2017. All inspectors who perform the role of the Duty Inspector were also required to attend a Continued Professional Development two day course between March and May 2017 around the management of threat, harm and risk and the need to document decisions clearly within CADs.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 1 · response
    Published 14 March 2018

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    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

    Sussex Partnership NHS Foundation Trust will respond directly to concerns one, two and three.

    Verbatim wording from the response

    “Points one, two and three (as numbered in the report) will be responded to by Sussex Partnership NHS Foundation Trust directly to you.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 1 · response
    Published 14 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing missing-person processes, policies, risk controls and staff training are considered sufficient to address the concerns.

    Verbatim wording from the response

    “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 1 · response
    Published 14 March 2018

    Open published response
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Data last updated 7 September 2026