4 Jan 2024 Stephen COSTER · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Stephen COSTER · 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
Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare 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 Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
Wider context from the report “f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment .
” Source location Stephen COSTER · 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 Actively review the emergency-escort policy.
Verbatim wording from the response “Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed.” Source location Response from HM Prison and Probation Service
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15 Dec 2023 John Robert Taylor · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 1
Failure to consider alternative transport to hospital 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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AI-generated summary
John Robert Taylor · 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
John Robert Taylor took a deliberate insulin overdose and contacted emergency services for help. The ambulance arrived more than 13 hours later, and he died in hospital on 27 July 2022; the inquest concluded that the delay contributed to his death. Concerns included inadequate checking of the property’s unlocked door, the failure to include this issue in the internal investigation, and the lack of consideration of using a taxi to transport him to hospital sooner.
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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 consider alternative transport to hospital
Wider context from the report “3. Consideration was not given to the possibility of sending a taxi to Mr Taylor so he might be conveyed to hospital quickly .
” Source location John Robert Taylor · 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 Implement the Emergency Ambulance Response Validation procedure, including welfare-call prioritisation and documented assessment of suitable alternative transport.
Verbatim wording from the response “In relation to the Management of Long Waits Policy, this policy was removed from use on 25 August 2022 and was replaced with the Procedure for Emergency Ambulance Response Validation and was implemented on 25 August 2022. The new procedure provides a process whereby welfare calls are only required to be made to patients who are alone. In these cases, the clinician is required to update the notes to make it clear when viewing the case list whether a welfare call is required or not by documenting ‘welfare’ or ‘no welfare’.” Source location Response from North East Ambulance Service
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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 A taxi was not appropriate because suicidal intent and other red flags made non-clinical transport unsafe.
Verbatim wording from the response “During the inquest you heard verbal evidence from a NEAS Clinical Section Manager who advised that in respect to the call on 18 July 2022, a taxi was not considered and would not have been appropriate given the nature of the call. The review of the clinician’s call undertaken by another Clinical Section Manager, shows that some red flags existed and should have prompted a higher level of caution, therefore the use of a taxi would not be appropriate. This was on the basis that the caller was expressing suicidal intent and plans, therefore not safe or appropriate to send a taxi in these circumstances. We have previously disclosed this report to your office and this was covered during live evidence by the Clinical Section Manager attending the inquest.” Source location Response from North East Ambulance Service
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13 Sep 2023 Geoffrey Douglas HOAD · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Spire Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department of Health and Social Care
Maintain additional ambulance capacity funded to expand capacity and improve response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Spire Healthcare Limited
Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
View source
Spire Healthcare Limited
Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
View source
Spire Healthcare Limited
Complete and register a group-wide risk assessment addressing ambulance transfer delays.
View source
Spire Healthcare Limited
Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
View source
Spire Healthcare Limited
Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
View source
Spire Healthcare Limited
Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
View source See 5 more actions
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AI-generated summary
Geoffrey Douglas HOAD · 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
Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.
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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 of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report “9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital.
10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.
11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers.
12. This concern has been raised at previous inquest.
” Source location Geoffrey Douglas HOAD · 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 Maintain additional ambulance capacity funded to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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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 new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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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 all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
Verbatim wording from the response “Action 2
Review of all transfers of care from SNH to Norfolk and Norwich Hospital in the period October 2021 to October 2023.” Source location Response from Spire Healthcare
Open published response
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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 Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “24. Spire Healthcare is acutely aware of the demands placed on NHS ambulance services and the resulting delays in ambulance response times.” Source location Response from Spire Healthcare
Open published response
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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 Complete and register a group-wide risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
Open published response
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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 Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
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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 Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
Verbatim wording from the response “29. The Inter Facility Transfer Group (IFTG) led by NNUH was set up to facilitate the inter facility transfer of unplanned emergency patients in the local area. Its first meeting took place in June 2022. As at October 2023, the membership of the group comprises representatives from the following organisations:” Source location Response from Spire Healthcare
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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 Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
Verbatim wording from the response “31. Following the inquest into the death of Mr Hoad and the subsequent concerns raised by HM Coroner, SNH raised concerns to the chair of the Interfacility Transfer Group that EEAST’s PFD witness had stated in court that the work of the IFTG was not expected to reduce delays in interhospital transfers. The chair of the IFTG met with EEAST’s Head of Patient Safety and it was agreed that, as of 02.10.23, they (EEAST’s PFD witness at the inquest) would join the IFTG in order that they are fully aware of the purpose of the group and involved in all associated actions. The intended benefits of the IFTG are as follows:” Source location Response from Spire Healthcare
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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 Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
Open published response
19 Jul 2023 Evelyn Mary Dutton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance transfer to hospital for elderly frail patients with hip fractures View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Improve ambulance response times through the urgent and emergency care recovery plan.
View source
NHS England
Increase ambulance capacity by growing the workforce.
View source
NHS England
Achieve the Ambulance Response Programme standards in the region.
View source
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AI-generated summary
Evelyn Mary Dutton · 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
Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.
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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 Delays in ambulance transfer to hospital for elderly frail patients with hip fractures
Wider context from the report “1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital . This was due to the demands on the ambulance service that day.
Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available;
2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022.
” Source location Evelyn Mary Dutton · 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 Improve ambulance response times through the urgent and emergency care recovery plan.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all ambulance call categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way as well as the flow of patients in and out of some NHS Trusts. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.” Source location Response from NHS England
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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 ambulance capacity by growing the workforce.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
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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 Achieve the Ambulance Response Programme standards in the region.
Verbatim wording from the response “Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the Ambulance Response Programme’s standards in the region.” Source location Response from NHS England
Open published response
19 Jul 2023 Thelma Mary Radmore · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance access and transfer to Emergency Departments View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Fund additional ambulance capacity and maintain the resulting capacity uplift through 2024/25.
View source
Department of Health and Social Care
Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.
View source
Department of Health and Social Care
Provide two-year funding to support timely and effective hospital discharge.
View source
Department of Health and Social Care
Continue working with NHS England to reduce ambulance response times and A&E waiting times.
View source See 1 more action
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AI-generated summary
Thelma Mary Radmore · 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
Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.
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× 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 ambulance access and transfer to Emergency Departments
Wider context from the report “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients;
2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards;
3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage;
4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally.
” Source location Thelma Mary Radmore · 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 Fund additional ambulance capacity and maintain the resulting capacity uplift through 2024/25.
Verbatim wording from the response “Regarding ambulance response times, a primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
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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 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulances can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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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 Provide two-year funding to support timely and effective hospital discharge.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulances can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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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 Continue working with NHS England to reduce ambulance response times and A&E waiting times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times and waiting times further, and the Government will continue to work with NHSE to achieve this.” Source location Response from Department of Health and Social Care
Open published response
24 Oct 2022 Glenys Roberts · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1
Failure of the vascular emergency transfer pathway to provide direct hospital admission 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
Betsi Cadwaladr University LHB Welsh Ambulance Services 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. 4
Betsi Cadwaladr University LHB
Map the emergency ischaemic limb patient journey across North Wales hospitals, identify delays and bottlenecks, and take steps to reduce them.
View source
Betsi Cadwaladr University LHB
Commence the vascular emergency bypass pathway for direct admission of suitable stable patients to the vascular ward and monitor its implementation until embedded.
View source
Welsh Ambulance Services NHS Trust
Finalise and implement the vascular emergency bypass pathway with BCU Health Board, including direct hospital admission arrangements and operational contact and destination details.
View source
Welsh Ambulance Services NHS Trust
Operate the implemented vascular bypass protocol across the South East Wales Vascular network for conditions including abdominal aortic aneurysm and ischaemic limb.
View source See 1 more action
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AI-generated summary
Glenys Roberts · 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
Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.
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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 of the vascular emergency transfer pathway to provide direct hospital admission
Wider context from the report “2. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow
” Source location Glenys Roberts · 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 Map the emergency ischaemic limb patient journey across North Wales hospitals, identify delays and bottlenecks, and take steps to reduce them.
Verbatim wording from the response “Prior to the Inquest, the Health Board had recognised these delays in time critical pathways and work had commenced on mapping out the current Emergency Ischaemic Limb Pathway across all three hospitals in North Wales. This was a multi-disciplinary approach including Emergency Departments (EDs), diagnostic services, pharmacy” Source location Response from Betsi Cadwaladr University Health Board
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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 Commence the vascular emergency bypass pathway for direct admission of suitable stable patients to the vascular ward and monitor its implementation until embedded.
Verbatim wording from the response “• Vascular surgeons and the emergency department clinicians have agreed to support the implementation of the South East Wales WAST Bypass Pathway. WAST crews will contact the Vascular Consultant having confirmed an emergency ischaemic limb and if the patient is stable they will be accepted and go straight to the vascular ward, by-passing ED. This is commencing from 01 December 2022 and will be monitored fortnightly through regular meetings with all key stakeholders to address issues or concerns which arise. This will continue until all parties are confident that the new pathway is fully embedded.” Source location Response from Betsi Cadwaladr University Health Board
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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 Finalise and implement the vascular emergency bypass pathway with BCU Health Board, including direct hospital admission arrangements and operational contact and destination details.
Verbatim wording from the response “The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines. This includes a range of conditions including abdominal aortic aneurysms (AAA) and ischemic limb, and has been implemented in the South East Wales Vascular network. BCU Health Board Vascular Network has accepted part of this pathway, the immediate bypass for ischemic limb to Ysbyty Glan Clwyd, but not for AAA. The Trust is currently finalising the pathway with BCU Health Board for implementation.” Source location Response from Welsh Ambulance Services NHS Trust
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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 Operate the implemented vascular bypass protocol across the South East Wales Vascular network for conditions including abdominal aortic aneurysm and ischaemic limb.
Verbatim wording from the response “The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines. This includes a range of conditions including abdominal aortic aneurysms (AAA) and ischemic limb, and has been implemented in the South East Wales Vascular network. BCU Health Board Vascular Network has accepted part of this pathway, the immediate bypass for ischemic limb to Ysbyty Glan Clwyd, but not for AAA. The Trust is currently finalising the pathway with BCU Health Board for implementation.” Source location Response from Welsh Ambulance Services NHS Trust
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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 The vascular pathway cannot be released for immediate use until the Health Board provides a contact number and destination.
Verbatim wording from the response “A draft document has been shared with BCU Health Board on 22 November 2022 to provide some BCU Health Board specific demographic and service delivery information, along with terminology although this can be considered non-essential with regard to implementation of the pathway and will not delay the release of this document to staff. The Trust is still waiting for a direct dial contact number that can be added to Consultant Connect and a destination for crews when patients have been accepted through this pathway. Once we have the information from the Health Board the information can be released for immediate use.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
13 Sep 2022 Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Delays in calling an ambulance when a resident’s condition requires emergency assistance View source
This report raised 10 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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AI-generated summary
Mr Peter Antony Joseph Pearson · 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
Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.
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× 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 an ambulance when a resident’s condition requires emergency assistance
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity .
” Source location Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report
Open source report
17 Jul 2022 Ronald Hartley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance attendance and transport for patients requiring hospital care View source
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
View source
Department of Health and Social Care
Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
View source
Department of Health and Social Care
Provide £20 million to upgrade the ambulance fleet.
View source
Department of Health and Social Care
Invest significantly in the ambulance workforce and support workforce.
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Ronald Hartley · Prevention of Future Deaths report
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Report summary
Ronald Hartley fell in his garden, fractured his neck of femur, underwent surgery, became increasingly frail, and died in hospital on 22 November 2021. His family reported being told that an ambulance would take approximately six hours to attend, so they transported him to hospital themselves, causing him significant pain and discomfort.
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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 Delays in ambulance attendance and transport for patients requiring hospital care
Wider context from the report “The evidence to the Inquest from the family was that when they found Mr Hartley and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr Hartley to hospital . He had fallen in his garden in November. The family were faced with a choice of waiting with him for 6 hours when he clearly needed to be in hospital or transporting him to hospital themselves. Given his distress and their concerns about the impact of the prolonged wait on him they decided to transport him to hospital in their own vehicle. The Inquest was told that this was extremely difficult and caused significant pain and discomfort to Mr Hartley.
” Source location Ronald Hartley · 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 Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Verbatim wording from the response “The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it.” Source location Response from Department of Health and Social Care
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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 Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” Source location Response from Department of Health and Social Care
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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 £20 million to upgrade the ambulance fleet.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” Source location Response from Department of Health and Social Care
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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 Invest significantly in the ambulance workforce and support workforce.
Verbatim wording from the response “The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by over 40% since September 2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service.” Source location Response from Department of Health and Social Care
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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 NHS will set out detailed recovery plans to improve urgent and emergency care performance.
Verbatim wording from the response “This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.” Source location Response from Department of Health and Social Care
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20 Jun 2022 Adele Angel Massoudi · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to prioritise calling an ambulance during a home birth emergency View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
RBFT
Include formal neonatal-resuscitation competency assessment in induction training.
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RBFT
Provide new midwives with maternity-unit shifts as part of induction and require annual completion of homebirth competency and confidence documents by maternity support workers.
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Adele Angel Massoudi · 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
Adele Angel Massoudi was born at home on 26 June 2020, transferred to hospital, and died there on 2 July 2020; the recorded cause of death was severe hypoxic ischaemic encephalopathy. The report identified delays in responding to meconium, inadequate fetal heart-rate monitoring, delayed transfer to hospital, inadequate communication with the family, and destruction of the placenta without retaining it for examination. Concerns focused on midwifery training and the retention of placentas for death investigation.
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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 prioritise calling an ambulance during a home birth emergency
Wider context from the report “She accepted in her evidence that it was open to her to ask someone else on scene, including a family member, to call for an ambulance. I remain concerned that the response of the key witness appears to be “I did what I could in difficult circumstances, and I had a lot to do”. The situation that the midwife was dealing with must indeed have been very stressful, but it is part of a midwife’s professional training to assess what is the most urgent thing to do first. That is not setting up equipment, waiting for contractions to finish et cetera. It is, in this scenario, to call an ambulance first and then do everything else afterwards. I remain concerned that, even after all the additional training, and having had this awful experience, this message is not coming through loud and clear from the witness evidence.
It is difficult to know whether a need for further training exists in relation to this witness, or more systemically. I am concerned that, having experienced this awful tragedy, and going through the HSIB investigation and the inquest process, anything other than full acceptance of the point was offered in evidence. I invite the trust to consider again the training of their midwives and whether the training provided to date is sufficient and safe, and to respond formally and in a Regulation 28 response.
” Source location Adele Angel Massoudi · 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 Include formal neonatal-resuscitation competency assessment in induction training.
Verbatim wording from the response “5. Consider strengthening competency assessment within mandatory training;
A formal assessment of neonatal resuscitation is now included during induction (delivery of inflation breaths, calling for help and SBAR handover). The practice development team are also undertaking training with RBFT resuscitation team to ensure consistency of formal assessments.” Source location Response from Royal Berkshire NHS Foundation Trust
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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 new midwives with maternity-unit shifts as part of induction and require annual completion of homebirth competency and confidence documents by maternity support workers.
Verbatim wording from the response “7. Consider offering opportunities for community staff to work in acute site with support, to enhance their clinical skills and confidence;
All new midwives have shifts within the maternity unit as part of their induction. The survey above will also identify whether any further training is indicated for acute site placements to be facilitated, alongside the new homebirth competency/confidence documents which all maternity support workers are required to complete annually with their line managers.” Source location Response from Royal Berkshire NHS Foundation Trust
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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 Current community intrapartum training is sound and effective, with no training-topic gaps identified, although recommendations will clarify and consolidate it.
Verbatim wording from the response “Overall, the external Consultant Midwife concluded that the current training offer for community staff providing intrapartum care at the Trust appears sound and effective and no gaps in training topics were identified. In conclusion she reported that we have many successes in the training we offer, with the service being open to feedback and actively developing in response to multiple drivers, including past incidents. The recommendations made within this review aim to support the service to clarify and consolidate this work, and we are committed to delivering accessible and relevant training on the management of intrapartum emergencies.” Source location Response from Royal Berkshire NHS Foundation Trust
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27 Apr 2022 Raphael Jeffery Gill · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to use emergency transport for a medical emergency View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
London Ambulance Service NHS Trust
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AI-generated summary
Raphael Jeffery Gill · 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
Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.
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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 use emergency transport for a medical emergency
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens , and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” Source location Raphael Jeffery Gill · 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 The care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.
Verbatim wording from the response “Mr Gill was appropriately assessed and promptly conveyed to the local emergency department. We have considered carefully if a pre-alert call (blue lights and sirens) was required. On balance, there is no absolute indication that a pre-alert call was required. Mr Gill was fully conscious and able to walk himself into the hospital. The time from the arrival of the conveying ambulance on the scene to leaving the scene for the hospital was 18 minutes; this is rapid and, on balance, could not have been quicker. Therefore, the LAS believes that this does not reflect a lack of urgency, that the time spent on the scene was not excessive and it does not follow that the fact Mr Gill was under arrest influenced the timeliness or appropriateness of his assessment, management or of his care.” Source location Response from London Ambulance Service
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.