Recurring concern

Unreliable activation of trauma response for serious injuries

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First reported 4 Dec 2013•Latest report 7 Mar 2022

Definition

What this concern includes

Includes failures in dedicated trauma-response activation and initial trauma assessment arrangements, including recognition of high-energy mechanisms or serious injury, triggering trauma or major-trauma protocols, summoning appropriate on-call clinicians and ensuring timely initial trauma-team response.

Not included

  • Excludes generic emergency-department delays, staffing or clinical-assessment failures where no trauma-specific activation or initial trauma-response deficiency is identified.
  • Excludes definitive trauma treatment, surgery, imaging or rehabilitation failures after the appropriate trauma response has been activated, unless the assertion also concerns activation or initial trauma assessment.
  • Excludes ambulance-service major-trauma categorisation where the report does not support a shared trauma-response activation condition.
  • Excludes isolated road collisions or injuries where no deficient trauma-response control is identified.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2013–2022

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

East and North Hertfordshire Teaching NHS Trust1
NHS England1
North Cumbria Integrated Care NHS Foundation Trust1
Recipient name withheld1
South East Coast Ambulance Service NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1

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. 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

    Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury

    Wider context from the report

    “2. London Ambulance have a different major trauma protocol to SECAMBS and the fact that Jo had been potentially hit by a car – even moving slowly- and had a head injury would have been enough for the Major Trauma protocol for London Ambulance. SECAMBS major trauma protocol was not triggered because even if she had been hit by a car it was not moving fast enough to justify a major trauma category (cat 2). ”

    Source location

    Josephine Celia BARKER · Prevention of Future Deaths report
    Page 8 · concerns

    Open source report

  2. West Sussex

    AI-generated summary

    Richard Lester Ridout · 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

    Richard Lester Ridout was involved in a single-vehicle road traffic collision on 20 January 2019 and was later readmitted with respiratory failure, where cervical fractures and pulmonary contusions were discovered. The inquest concluded that he died from Influenza A and streptococcal pneumonia causing sepsis and multiple organ failure. Concerns were raised that the assessment and escalation of treatment after the collision did not include a trauma call, trauma CT scan, or cervical spine imaging despite the reported collision circumstances, injuries, neck pain and medication use.

    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 put out a trauma call for high-energy road traffic collisions

    Wider context from the report

    “(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out. (2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC. ”

    Source location

    Richard Lester Ridout · 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

    Develop a trauma-management protocol addressing differing collision-speed accounts, reduced clinical signs in patients using opiates or sedatives, and consideration of trauma calls.

    Verbatim wording from the response

    “We can confirm that a protocol is being developed for the management of patients who have sustained trauma where there are differing accounts of the speed involved as well as emphasising that patients who are on long term opiates or sedatives, whether prescribed or not, will often have reduced clinical signs so the level of clinical suspicion needs to be increased. The need to give consideration to instigating a trauma call when there is an unclear account of the collision and, in particular, potential of a high speed impact, is included as part of the protocol.”

    Source location

    2019-0331-Response-by-Western-Sussex-Hospitals
    Page 1 · response
    Published 8 November 2019

    Open published response

  3. Hertfordshire

    AI-generated summary

    Tillie SPENCER-ADAMS · 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

    Tillie Spencer-Adams was found unresponsive in her mother's bed on 18 June 2018 and could not be resuscitated. The medical cause of death was unascertained, with the inquest concluding Sudden Unexpected Death in Infancy. The report identified concern that injuries potentially sustained in a road traffic collision, including fractures and head injuries, may have been overlooked when she attended hospital on 4 May 2018.

    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 identify serious injuries following road traffic collisions

    Wider context from the report

    “(1) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she is likely to have suffered serious injuries (fractures and head injuries) which appear to have been overlooked. ”

    Source location

    Tillie SPENCER-ADAMS · 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 the care provided on 4 May 2018.

    Verbatim wording from the response

    “The contents of your letter were of grave concern to me and therefore I asked ████████ Clinical Director for Paediatrics, to review the care provided when Tillie attended on 4th May 2018.”

    Source location

    2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
    Page 1 · response
    Published 22 November 2019

    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

    Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.

    Verbatim wording from the response

    “Whilst the triage nurse in ED noted a red mark on Tillie’s head, this was not observed by either the Paediatric doctors who reviewed her, nor any of the Paediatric nurses. In addition, Tillie did not exhibit any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan. Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout.”

    Source location

    2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
    Page 2 · response
    Published 22 November 2019

    Open published response

  4. North and West Cumbria

    AI-generated summary

    Keith Thomas Graham · 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

    Keith Thomas Graham was involved in a road traffic collision after colliding with a bullock while travelling by motorcycle and later died from multiple injuries on 28 May 2012. Concerns included the timing of summoning on-call clinicians, the use of CT scanning for seriously injured trauma patients, and the time between presentation and theatre, as well as a misplaced chest drain that damaged the liver.

    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 ensure timely summons of on-call clinicians for seriously injured trauma patients

    Wider context from the report

    “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre. ”

    Source location

    Keith Thomas Graham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026