Recurring concern

Failure to provide timely ambulance-based treatment for suspected serious infection

First to latest report 20 Dec 2019 — 7 Feb 2026

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures of dedicated ambulance-based assessment, treatment, escalation, or access arrangements that delay or prevent timely provision of necessary treatment for patients with suspected serious infection while emergency department admission is delayed.

What is not included
  • Excludes generic emergency department admission delays that are not linked to the provision of ambulance-based treatment for suspected serious infection.
  • Excludes antibiotic prescribing, selection, allergy checking, or administration failures unrelated to ambulance-held patients with suspected serious infection.
  • Excludes generic staffing, training, documentation, equipment, or patient-flow deficiencies unless the report directly ties them to this ambulance-based serious-infection treatment pathway.

Reports and published responses 2 reports

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

  1. Blackpool and the Fylde

    AI-generated summary

    Janet Springall · 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

    Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection

    Wider context from the report

    “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department. When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department. Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital. Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment. I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done. ”

    Source location

    Janet Springall · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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 Care Quality Commission will provide a separate response to the concerns.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 12 February 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

    The internal review found no evidence that CQC advised the trust not to treat patients remaining on ambulances.

    Verbatim wording from the response

    “Our internal review has found no evidence; written or verbal within our records that CQC advised the trust not to treat patients on ambulances. CQC remain committed to encouraging care services to improve by working with the trust and system partners to ensure that patients receive safe and timely care, including during periods of sustained operational pressure.”

    Source location

    Response from Care Quality Commission
    Page 3 · response
    Published 12 February 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

    Providing operational clinical advice about where or how specific patients should be treated falls outside CQC’s remit.

    Verbatim wording from the response

    “For clarity, CQC inspectors do not provide operational clinical advice to providers, including advice about how or where treatment should be delivered to specific patients. This is not within CQC remit, and inspection teams are trained to ensure that their role is to assess and report on the quality and safety of care, rather than to direct clinical practice. CQC recognises that informal conversations during inspections can sometimes lead to differing interpretations and CQC are committed to being as clear as possible about the limits of our role. However, CQC are unable to evidence that a conversation covering these issues took place during our inspection.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 12 February 2026

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Samantha Brousas · 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

    Samantha Brousas became critically ill with suspected sepsis and was taken to hospital, where she was diagnosed with septic shock secondary to pneumonia and died from a naturally occurring infection. The report identified concerns about the absence of a pre-alert to the emergency department, the inability of paramedics to administer intravenous antibiotics, and the lack of a clear process for escalating concerns about delayed admission.

    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

    Unavailability of intravenous antibiotic administration by ambulance paramedics when emergency department admission is delayed

    Wider context from the report

    “(2) I heard evidence during the course of the inquest that the first line treatment for sepsis was the administration of anti-biotics within an hour of arrival at a hospital consistent with the SEPSIS SIX and NICE guidelines. I also heard evidence that it was currently beyond the scope of the practice of WAST paramedics to administer antibiotics intravenously in an ambulance. Given the importance of the role of the Paramedic in the early diagnosis of Sepsis my concern is that when a patient is unable to be admitted into the emergency department in similar situations as the deceased, the absence of the administration of antibiotics increases the mortality risk of such patients which could be addressed by exemptions and local organisational level policies and procedures. ”

    Source location

    Samantha Brousas · 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

    Conduct the PhRASe feasibility study, including paramedic screening, randomisation, blood-culture collection and intravenous antibiotic administration, and complete anonymised follow-up analysis.

    Verbatim wording from the response

    “The PhRASe (Prehospital Recognition and Antibiotics for 999 patients with severe Sepsis) study was designed to determine if it was feasible for Trust paramedics to select and screen eligible patients, then randomise them to usual care or intervention (blood culture collection and administration of IV antibiotics). The main purpose of the study was to gather evidence, to inform the feasibility of a definitive study that could examine the effectiveness of prehospital antibiotics. This study is in the final stages of data analysis of anonymised follow-up via the SAIL databank.”

    Source location

    2019-0443-Response-from-the-Welsh-Ambulance-Services
    Page 3 · response
    Published 3 January 2020

    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

    The Trust will not provide routine pre-hospital antibiotics because evidence, training, equipment, costs and antimicrobial-resistance concerns constrain implementation.

    Verbatim wording from the response

    “Therefore, the current evidence base is not strong enough to demonstrate the benefits of out-of-hospital administration of antibiotics in sepsis by all paramedics, including time taken to train, the costs involved to purchase the additional medications and equipment, and maintain competency in the use of the drugs. In addition, controlled use of antibiotics is considered best practice to prevent antimicrobial resistance, which is on the increase.”

    Source location

    2019-0443-Response-from-the-Welsh-Ambulance-Services
    Page 3 · response
    Published 3 January 2020

    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

    Health Board Emergency Department staff are responsible for initiating antibiotics for patients delayed in ambulances because they prescribe and select appropriate treatment.

    Verbatim wording from the response

    “The Trust advocates that any administration of antibiotics for patients with red flag sepsis should be initiated within the Emergency Department and not in the back of an Emergency Ambulance. For patients held in the back of ambulances due to excessive”

    Source location

    2019-0443-Response-from-the-Welsh-Ambulance-Services
    Page 3 · response
    Published 3 January 2020

    Open published response

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

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Data last updated 7 September 2026