Concerns raised 1
Failure to coordinate cardiac-arrest responses View source
This report raised 6 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
SPFT
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
View source
SPFT
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
View source
SPFT
Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.
View source
×
AI-generated summary
Kristian Edward Allen · 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
Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.
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 coordinate cardiac-arrest responses
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised . Nobody appeared to be in charge , staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” Source location Kristian Edward Allen · Prevention of Future Deaths report
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 Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
Verbatim wording from the response “Response to cardiac arrest
I appreciate your concern in relation to staff not being properly able to deal with cardiac arrests. You will have heard how this was recognised within the Trust's PSII and the need to strengthen preparedness and response to medical emergencies, including opioid overdose, resulted in recommended action. The identified action was the need to increase staff confidence in administering Immediate Life Support (ILS). I am informed that the Inquest heard of the impact upon staff of conducting ILS and how their confidence can be impacted by the rarity of having to conduct ILS. I confirm, as you heard, that as a direct action from the PSII into Kristian's death the Trust introduced regular simulation training ie: unannounced emergency simulations to which staff then have to respond.” Source location Response from Sussex Partnership Foundation Trust
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 Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
Verbatim wording from the response “As you also heard in evidence the Trust's Resus policy has been updated to formalise the inclusion of simulation as standard in both clinical and non-clinical areas to enhance and embed medical emergency and cardiac arrest training, thereby ensuring staff remain competent and confident with emergency processes and procedures. The policy stipulates that simulations will be completed monthly throughout SPFT in inpatient hospitals. As ████████ informed you, the most recent simulation on Kristian's ward took place on 20th May, involving 8 staff and simulated a scenario of an opioid overdose leading to cardiac arrest. I am informed that feedback from the ILS team was that the ward-team's response was well led.” Source location Response from Sussex Partnership Foundation Trust
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 Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.
Verbatim wording from the response “Additionally, Mill View Hospital, as a whole, have been subject to external review by recognised specialist consultants in organisational performance and service improvement. Their work has focused on strengthening ward-level processes and operational consistency, including clarifying roles and responsibilities, improving documentation standards, and ensuring that actions agreed in MDTs and reviews are clearly recorded, owned and followed through. This has supported the development of a structured ward-level improvement plan, enabling learning, including from PSIIs, to be translated into consistent day-to-day practice and more reliable delivery of care processes.” Source location Response from Sussex Partnership Foundation Trust
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 Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
Verbatim wording from the response “In summary, given the comprehensive range of actions already taken by the Trust there are no further new actions that I consider the Trust needs to take. That said, as I recognised above, all improvement requires sustained, committed focus. So, whilst I can already say that the actions described above are now embedded within policy, training, governance and ward-level quality improvement processes, which are subject to ongoing monitoring to ensure improvements continue, I would like to assure you that the oversight and focus on” Source location Response from Sussex Partnership Foundation Trust
Open published response
9 Mar 2026 Terrence FROST · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure of GPs to promptly communicate with the Medical Assessment Unit or Accident and Emergency department View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Terrence FROST · 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
Terrence Frost died at Ipswich Hospital on 17 July 2024 after a sudden collapse and cardiac arrest during a final admission following repeated presentations with abdominal pain, rectal bleeding and concerning blood test results. Postmortem examination identified significant cardiac and vascular disease, and sepsis was considered to have played a factor despite no infection being identified. The principal concerns were difficulties contacting the hospital’s Medical Assessment Unit and Accident and Emergency department, and Terrence’s five-hour wait in Accident and Emergency before being seen.
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 GPs to promptly communicate with the Medical Assessment Unit or Accident and Emergency department
Wider context from the report “Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16th July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance.
The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit.
In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission.
After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre-alert the Accident and Emergency department to his arrival.
The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through.
As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival.
Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival.
I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered.
” Source location Terrence FROST · Prevention of Future Deaths report
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 Restrict the Medical Assessment Unit bleep to external calls, increasing capacity for timely responses and reducing call queues.
Verbatim wording from the response “The bleep in the Medical Assessment Unit is now only used for external calls into the departments, increasing the capacity to answer calls in a timely manner and resulting in shorter call waiting queues.” Source location Response from East Suffolk & North Essex NHS Trust
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 electronic messaging, bleep arrangements and ambulance pre-alert processes are considered an adequate response to communication concerns.
Verbatim wording from the response “In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users.” Source location Response from East Suffolk & North Essex NHS Trust
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 Primary care providers are expected to request ambulance attendance for patients with suspected sepsis or life-threatening conditions requiring hospital conveyance.
Verbatim wording from the response “In circumstances where a patient is deemed to have suspected sepsis or be in a life-threatening condition presenting to a primary care provider, the expected course of action would be for the primary care provider to seek ambulance attendance to convey the patient to hospital. This would result in the ambulance service pre-alerting the Emergency Department of the patient’s attendance, through a designated hot line for ambulance pre-alerts.” Source location Response from East Suffolk & North Essex NHS Trust
Open published response
Concerns raised 1
Failure to establish ambulance staff role and assessment status View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Brian Ingram · 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
Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.
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 establish ambulance staff role and assessment status
Wider context from the report “6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment .
” Source location Brian Ingram · Prevention of Future Deaths report
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 Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
Verbatim wording from the response “1.1 Since the inquest, LML has issued an organisation-wide memorandum concerning the mandatory requirement for all staff to clearly identify themselves to all patients, families and partner agencies. This information must include” Source location Response from Cornwall Partnership NHS Foundation Trust
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 Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Verbatim wording from the response “2.6 There has been a team-wide communication to all MIU staff, reiterating the requirement for all patients arriving by ambulance (SWAST or otherwise), to be physically assessed and have a handover and history taken in the back of the ambulance, before the patient is accepted into the MIU. It has been clarified that the patient should only be booked in to the MIU, once the clinician has confirmed their acceptance with the admin team. Patients arriving by ambulance are not to be booked in until they have been assessed as suitable for treatment at the MIU.” Source location Response from Cornwall Partnership NHS Foundation Trust
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 Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Verbatim wording from the response “3.8 From the perspective of CFT, all MIU staff have been reminded that the PCR, whether this is in paper form or any electronic PCR, should be received from the ambulance crew before the patient is booked in. Learning has been identified following the inquest in relation to patient handover at the MIU. It is acknowledged by CFT that there was an over-reliance on a verbal handover from the ambulance crew (believed by MIU staff to be paramedics), which had an impact on the initial assessment by the MIU practitioner. All staff have been reminded of the importance of taking a full patient history and all available patient documentation, prior to accepting the patient on to the MIU. This learning and required actions have been shared with staff via email and have featured on the agenda of MIU staff meetings over the last 12 months.” Source location Response from Cornwall Partnership NHS Foundation Trust
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1
Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings 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
HM Prison and Probation Service Oxleas NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
HM Prison and Probation Service
Direct HMP Elmley staff to follow local medical-emergency procedures consistently, including responsibilities for resuscitation, restraints and ligature removal.
View source
Oxleas NHS Foundation Trust
Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.
View source
South East Coast Ambulance Service NHS Foundation Trust
Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.
View source
South East Coast Ambulance Service NHS Foundation Trust
Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.
View source
South East Coast Ambulance Service NHS Foundation Trust
Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.
View source See 2 more actions
×
AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.
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 Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
Wider context from the report “(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primary in an acute medical emergency in a custodial setting .
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
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 Direct HMP Elmley staff to follow local medical-emergency procedures consistently, including responsibilities for resuscitation, restraints and ligature removal.
Verbatim wording from the response “It is essential that all staff understand their responsibilities when responding to a medical emergency, including actions relating to resuscitation, the use of restraints, and the removal of ligatures. Local procedures are in place at HMP Elmley to support a coordinated and effective response, and staff have been directed to adhere to these consistently.” Source location Response from HM Prison & Probation Service
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 Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.
Verbatim wording from the response “As part of this collaboration, bronze, silver, and gold command training is being incorporated into the Oxleas service and is currently in the process of being sourced appropriately. Additionally, a memorandum of understanding is being jointly drafted by HMPPS, Kent Fire and Rescue, Oxleas, and SECAMbs to outline each agency's responsibilities and to facilitate coordinated joint working during major incidents.” Source location Response from Oxleas NHS Foundation Trust
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 Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.
Verbatim wording from the response “Importantly, the SECAmb Resilience Team have now completed the development of Site Specific Response Plans (SSRP) for all prison sites within our region, which has included discussion around the use of ‘Code Red and Code Blue’ terminology. These SSRPs provide a predefined attendance protocol for complex prison incidents, including the deployment of a structured command presence at the scene. They are accessible to both the Emergency Operations Centre (EOC) and frontline crews, and offer pre-agreed access, egress, and rendezvous point (RVP) information, along with site-specific risk details that must be considered to ensure a coordinated and informed response to these challenging locations. More broadly, a memorandum of understanding (MOU) is being written between SECAmb, HMP Elmley and Oxleas to articulate roles and responsibilities when attending prisons incidents.” Source location Response from South East Coast Ambulance Service
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 Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.
Verbatim wording from the response “Regionally, the SECAmb Medway Operating Unit Leadership team meet with the prison’s healthcare team and governors every quarter and review any incidents or escalations with a view to learning and improving. Building on this, the Medway operating unit team have been invited to CPD events at the prison, and they have offered to provide restraint continuing professional development for the Trust following Azroy’s request which will be explored in relation to ongoing education and development programs for SECAmb staff. At an organisational level, a new section has been added to SECAmb’s Incident Response Plan which provides a comprehensive command-and-control framework for responding to incidents within HM Prison establishments.” Source location Response from South East Coast Ambulance Service
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 Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.
Verbatim wording from the response “patients within secure settings like a prison is a key action for the Trust, both in terms of engaging with prison healthcare providers and ensuring that our staff understand where primacy sits.” Source location Response from South East Coast Ambulance Service
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 Healthcare professionals or paramedics, rather than prison staff, are responsible for leading medical interventions beyond first aid or CPR.
Verbatim wording from the response “HMPPS policy on responding to medical emergencies is set out in Prison Service Instruction 03/2013. Operational staff are responsible for ensuring that appropriate medical support is summoned promptly – whether from on-site healthcare services or the ambulance service – and for enabling healthcare professionals to access and treat the individual without delay. While prison staff will often be the first on scene, they are not expected to lead medical interventions beyond the scope of first aid or CPR where healthcare professionals or paramedics are present. Their role is to support, facilitate, and assist clinical staff as required.” Source location Response from HM Prison & Probation Service
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 arrangements establish Oxleas’ responsibility and leadership for acute medical emergencies, with paramedics supporting Oxleas staff when required.
Verbatim wording from the response “It is recognised that in this very sad incident there may have been confusion regarding primacy in a medical emergency. This incident pre-dates Oxleas NHS Foundation Trust’s delivery of healthcare services at HMP Elmley. The Trust is clear that, as the primary healthcare provider at HMP Elmley, Oxleas NHS Foundation Trust retains responsibility for the care and treatment of prisoners until their departure from custody, regardless of whether this occurs via ambulance or other means, including primacy in an acute medical emergency. There is an inpatient healthcare team at HMP Elmley and staff attend and lead healthcare emergencies as normal practice. Where paramedic support is required, our staff work with paramedics to ensure that their skills are deployed in partnership with the Oxleas staff during the incident.” Source location Response from Oxleas NHS Foundation Trust
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 Primacy of care in prisons rests with commissioned prison healthcare services, while ambulance staff assume responsibility after handover and departure.
Verbatim wording from the response “For the sake of clarity, primacy of care within a prison environment rests with commissioned prison healthcare services as each prison will have its own safe systems of work and identified procedures for the provision of emergency care. Ambulance Service staff responding to emergencies within a prison will work in liaison and in conjunction with healthcare teams from that facility in line with their scope of practice and in accordance with SECAmb policies and procedures and will assume responsibility for patient care at the point of handover and departure from that facility. This is particularly important as prison healthcare staff will undertake a lead role in risk assessment processes undertaken in facilities prior to transportation.” Source location Response from South East Coast Ambulance Service
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2
Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings View source Failure to establish a communication strategy during critical medical emergencies in custodial settings View source
Linked response
Department of Health and Social Care
×
AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and hospital treatment. The principal concerns included confused communication and unclear command structures among prison staff, healthcare professionals and paramedics, disproportionate and prolonged restraint, delays in obtaining medical assistance and starting CPR, and inadequate consideration of his breathing and positioning.
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 establish clear command and control arrangements during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities . Those attending the scene did not establish any sort of communication strategy or command structure . During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(2)
(3)
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
Open source report × 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 establish a communication strategy during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused . There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(2)
(3)
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
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 HM Prison and Probation Service is responsible for leadership, command and control of prison emergencies, including medical emergencies.
Verbatim wording from the response “I can confirm that HM Prison and Probation Service is the public body which takes primacy for the leadership, command and control of an emergency situation in prison, including a medical emergency. Healthcare staff within a prison should respond to and provide any emergency medical treatment, such as CPR, until a paramedic arrives on scene.” Source location Response from Department of Health and Social Care
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 Ambulance Service is expected to provide further detail about paramedics’ role in medical emergencies within prisons.
Verbatim wording from the response “I understand that you have issued a separate Regulation 28 report to the Director General Chief Executive of HM Prison and Probation Service; and one to the Governor at HMP Elmley, Oxleas NHS Foundation Trust and the South East Coast Ambulance Service. I would expect the Ambulance Service to provide more detail about the role of paramedics in medical emergencies within the prison estate.” Source location Response from Department of Health and Social Care
Open published response
11 Mar 2025 NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3
Failure to coordinate detention and medical staff roles during a medical emergency View source Failure of communication between detention and medical staff to facilitate prompt CPR commencement View source Lack of protocols defining detention and medical staff roles during a medical emergency in a cell 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
Leeds Community Healthcare NHS Trust West Yorkshire Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
West Yorkshire Police
Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
View source
Leeds Community Healthcare NHS Trust
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
View source
Leeds Community Healthcare NHS Trust
Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
View source
Leeds Community Healthcare NHS Trust
Include coordination of response in investigations of life-threatening incidents and deaths in custody.
View source
Leeds Community Healthcare NHS Trust
Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
View source See 2 more actions
×
AI-generated summary
NICHOLAS OLIVER JAMES GEDGE · 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
Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.
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 coordinate detention and medical staff roles during a medical emergency
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person . There did not appear to be a co-ordinated approach to assisting Nicholas , with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook .
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Source location NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
Open source report × 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 communication between detention and medical staff to facilitate prompt CPR commencement
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement .
” Source location NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Source location NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
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 custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
Verbatim wording from the response “3. Nevertheless, the Chief Constable intends to review the contracts, policies and procedures that are in place between Leeds Community Healthcare and the Force, in partnership with Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers and Healthcare Professionals in custody in an emergency situation are sufficiently clear.” Source location Response from West Yorkshire Police
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 Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
Verbatim wording from the response “• In addition to the organisational mandatory bespoke life support training, LCH will expand the scenario aspect of training to include simulation exercises in the custody suite environment with the aim of improving the co-ordination between LCH staff and detention officers in the event of emergency scenarios.” Source location Response from Leeds Community Healthcare NHS Trust
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 Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
Verbatim wording from the response “• A working group consisting of LCH HCP’s, led by a clinical team manager, has commenced to review the Death in Custody (DIC) procedure.” Source location Response from Leeds Community Healthcare NHS Trust
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 Include coordination of response in investigations of life-threatening incidents and deaths in custody.
Verbatim wording from the response “• The service will ensure that they include ‘coordination of response’ in the investigation process of incidents where there has been a life-threatening response or a DIC.” Source location Response from Leeds Community Healthcare NHS Trust
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 Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
Verbatim wording from the response “• The procedure will be agreed with the police to ensure the coordination of response in life threatening situations is robust.” Source location Response from Leeds Community Healthcare NHS Trust
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 training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
Verbatim wording from the response “(i) Until the custody Healthcare Professional attends, they are to follow their training and provide Basic Life Support, including giving CPR to people who are not breathing.” Source location Response from West Yorkshire Police
Open published response
6 Nov 2024 Simon Boyd · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Cancellation of ambulance responses without discussion with callers View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Simon Boyd · 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
Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.
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 Cancellation of ambulance responses without discussion with callers
Wider context from the report “2. A further matter of concern arises from the potential under the NHS Pathways paradigm for an ambulance response to be cancelled without this first being discussed with the person who has felt it necessary to dial 999 and request an ambulance in the first place .
” Source location Simon Boyd · Prevention of Future Deaths report
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 Ambulance validation and cancellation fall outside NHS Pathways’ remit.
Verbatim wording from the response “Simon was subsequently spoken to by a clinician within the Greater Manchester Clinical Assessment Service, who would have cancelled the ambulance. This validation and cancellation of an ambulance is not within the remit of the NHS Pathways system, and no data is provided back to NHS Pathways or the provider as to the changing of a disposition. Should the Coroner wish to investigate this further, he would be best placed contacting the Greater Manchester Clinical Assessment Service.” Source location Response from NHS England
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 Greater Manchester Clinical Assessment Service is responsible for investigating the ambulance validation and cancellation.
Verbatim wording from the response “Simon was subsequently spoken to by a clinician within the Greater Manchester Clinical Assessment Service, who would have cancelled the ambulance. This validation and cancellation of an ambulance is not within the remit of the NHS Pathways system, and no data is provided back to NHS Pathways or the provider as to the changing of a disposition. Should the Coroner wish to investigate this further, he would be best placed contacting the Greater Manchester Clinical Assessment Service.” Source location Response from NHS England
Open published response
24 Jul 2024 Regan Edwin James SMITH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Lack of national standards and guidance requiring confirmation that basic observations are received by Accident and Emergency personnel 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
×
AI-generated summary
Regan Edwin James SMITH · 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
Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of basic observations.
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 Lack of national standards and guidance requiring confirmation that basic observations are received by Accident and Emergency personnel
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians.
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case.
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units.
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel .
” Source location Regan Edwin James SMITH · Prevention of Future Deaths report
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 Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Verbatim wording from the response “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.” Source location Response from DHSC
Open published response
5 Jan 2024 Tammy Mary Louise WATKINS · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Unclear responsibility for calling a medical emergency View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Tammy Mary Louise WATKINS · 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
Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.
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 Unclear responsibility for calling a medical emergency
Wider context from the report “4. Emergency Medical Calls
There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service. It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient .
Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed.
This appears to be a training issue.
” Source location Tammy Mary Louise WATKINS · Prevention of Future Deaths report
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 and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.
Verbatim wording from the response “4. Emergency Medical Calls
The process for emergency medical calls within Rampton Hospital has been reviewed and the process has been reinforced back to all staff that where immediate concerns are present regarding the physical health of a patient, it is expected that they will call for an ambulance. This is reviewed in line with the increased senior leadership and local learning.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
4 Jan 2024 Stephen COSTER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1
Breakdown in healthcare-prison communication about emergency hospital transfer View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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.
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 Breakdown in healthcare-prison communication about emergency hospital transfer
Wider context from the report “e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency . Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster’s condition resulting in delay in arranging for his urgent escort and transfer to hospital.
” Source location Stephen COSTER · Prevention of Future Deaths report
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 Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
Verbatim wording from the response “Following the death of Mr Coster and the PPO’s recommendations, the Deputy Governor and Head of Safety conducted a review into the circumstances of the prison escort to hospital. Their findings identified a need for improved communication with and greater clarity from healthcare staff to ensure that urgency of the matter is made clear to prison staff. This has been shared with healthcare.” Source location Response from HM Prison and Probation Service
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.