Recurring concern

Ineffective communication during medical emergencies

First to latest report 1 Oct 2013 — 26 May 2026

Reports that mention this concern
42
Times this concern has been raised
49
Stated actions linked to this concern
61

What this concern includes

Includes deficiencies in communication, information transfer, handover, communication strategy or role clarity that are directly dedicated to coordinating or escalating a medical emergency response, including communication between healthcare staff and prison, control-room, ambulance or other responding personnel.

What is not included
  • Excludes communication deficiencies unrelated to a medical emergency response.
  • Excludes standalone training, staffing, equipment, documentation or clinical-assessment deficiencies unless the report directly identifies their effect on medical-emergency communication.
  • Excludes failures confined to a specific clinical guideline or treatment decision where emergency communication is not the shared unsafe condition.
  • Excludes generic information-sharing problems that are not tied to coordinating or escalating a medical emergency.

Reports and published responses 42 reports

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

  1. Central Hampshire

    AI-generated summary

    Mark William Berry · 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

    Mark William Berry suffered a cardiac arrest after apparently taking morphine or heroin and pregabalin, and was declared dead in hospital. The medical cause of death was recorded as morphine toxicity. Concerns included delays in notifying police, incomplete handover information about the address where he was found, and communication of information from a private ambulance service to the control room.

    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 convey address information from private ambulance services to SCAS control room before staff go off duty

    Wider context from the report

    “3. Finally, the lack of an address may require further consideration of how basic but potentially important data is conveyed to SCAS control room from a private ambulance service especially before staff go off duty and thereby avoiding delay. ”

    Source location

    Mark William Berry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    David Sheppard · 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

    David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.

    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 staff to communicate with each other during emergency response

    Wider context from the report

    “a. The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter. The carer who started CPR had very poor English and also gave evidence through an interpreter. The evidence heard at the inquest was that the response to this emergency was chaotic. Inability of staff to communicate with each other contributed to the chaos and poor decision making. ”

    Source location

    David Sheppard · Prevention of Future Deaths report
    Page 2 · 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

    Language testing is not required for non-regulated care workers, although employers must ensure they can communicate effectively.

    Verbatim wording from the response

    “There is no requirement for language testing non-regulated workers, such as care staff. However, social care employers are responsible for ensuring that their staff are trained and competent for the tasks they are recruited to do. This includes the ability to communicate effectively.”

    Source location

    David-Sheppard-Response
    Page 3 · response
    Published 10 July 2017

    Open published response

  3. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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

    Delay in providing the ambulance with the prison gate location

    Wider context from the report

    “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call. The LAS controller did not ask at the very outset. The ideal would be for the information to be given at the very beginning of any emergency call. (I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.) ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 3 · 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

    Require prison control rooms to provide the gate location at the beginning of ambulance calls and brief staff on the requirement.

    Verbatim wording from the response

    “The separate report addressed to the Governor raises concern about the fact that the prison’s control room did not immediately provide the London Ambulance Service (LAS) with the gate location when they requested the attendance of an ambulance. I can confirm that since Mr Blair’s death, colleagues at Pentonville have met the LAS to discuss this issue, and it has been agreed that the prison gate location will be”

    Source location

    2016-0196-Response-by-NOMS
    Page 1 · response
    Published 19 May 2016

    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 Computerised Gazetteer with both HMP Pentonville vehicular entrances and their postal addresses.

    Verbatim wording from the response

    “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.”

    Source location

    2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 19 May 2016

    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

    Request HMP Pentonville staff to state the required ambulance entrance at the beginning of every 999 call.

    Verbatim wording from the response

    “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.”

    Source location

    2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 19 May 2016

    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

    Deliver refresher training requiring emergency medical dispatchers to confirm the HMP Pentonville entrance at the start of each call.

    Verbatim wording from the response

    “I have been assured by ████████, the LAS’s Deputy Director of Operations (Control Services), ████████ that in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.”

    Source location

    2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 19 May 2016

    Open published response

  4. Manchester West

    AI-generated summary

    Christopher John 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

    Christopher John Smith died instantaneously after jumping from Barton Bridge on 15 July 2015. The principal concern was a 12-minute delay in contacting the ambulance service, caused by a communication breakdown about which service was responsible for making the call, although this did not affect the outcome in this case.

    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 immediately establish responsibility for calling an ambulance

    Wider context from the report

    “1) It was clear from the evidence that there was a 12 minute delay in the police contacting the ambulance – the police were notified of the incident but did not contact North West Ambulance Service immediately. 2) In the circumstances of this Inquest I was satisfied that this delay had not had any relevance with regards to Christopher Smith’s death, given that the pathologist had concluded that his death was instantaneous. Any delay in the ambulance arriving was therefore not going to save his life. 3) However, it is perfectly possible to foresee circumstances where a delay in calling for an ambulance may have an effect on the outcome, where someone has jumped or fallen from a lesser distance. 4) I was told that the 12 minute delay was due to a breakdown in communication between Greater Manchester Police control room and the Motorway Control – Greater Manchester Police thought that the Motorway Control were contacting the ambulance and vice versa. 5) It seems to me that procedure should be in place whereby it is immediately established who is going to be responsible for calling the ambulance to avoid any delays, and the ambulance is called for at once. ”

    Source location

    Christopher John Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Cumbria

    AI-generated summary

    Alice Anne McMeekin · 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

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    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 communicate significant risk information to ambulance and psychiatric staff

    Wider context from the report

    “1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”

    Source location

    Alice Anne McMeekin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. County Durham and Darlington

    AI-generated summary

    Sharon Louise Suki Butcher · 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

    Sharon Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.

    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

    Delays and lack of clarity in control-room responses to medical emergencies

    Wider context from the report

    “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

    Source location

    Sharon Louise Suki Butcher · Prevention of Future Deaths report
    Page 1 · concerns

    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 use appropriate codes for medical emergencies

    Wider context from the report

    “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

    Source location

    Sharon Louise Suki Butcher · 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

    Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.

    Verbatim wording from the response

    “HMP Frankland revised their local contingency plans and re-issued instructions following the death of Ms. Sharon Butcher to ensure that all staff understood, that they must not delay in calling an ambulance in all cases where there are serious concerns about the health of an offender.”

    Source location

    2015-0129-Response-by-NOMS
    Page 1 · response
    Published 31 March 2015

    Open published response

  7. Staffordshire South

    AI-generated summary

    Adam Amos Williams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Adam Amos Williams, a serving prisoner aged 29, collapsed at HMP Featherstone on 5 March 2013 and died at New Cross Hospital on 6 March 2013 from a sub-arachnoid haemorrhage. The concerns raised related to communication between prison healthcare staff during emergencies, whether dynamic assessments considered the need for restraint, and the possible benefit of additional CCTV in prison common areas.

    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

    Inadequate communication between healthcare staff during emergencies

    Wider context from the report

    “(1) Picking up on recommendation 2 from the Prisons and Probation Ombudsman’s report I wonder if there is a training need for nursing staff at the prison regarding communication between healthcare staff in the event of an emergency. Can it be improved be it face to face, over the radio or otherwise? ”

    Source location

    Adam Amos Williams · 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

    Ensure two healthcare staff attend every health emergency radio call, with lone nurses requesting colleague attendance.

    Verbatim wording from the response

    “The sharing of medical information over the radio has been considered by the prison and healthcare provider who are conscious that a secure bandwidth would need to be available for this process to be able to share confidential information over the airways. However, at present two members of healthcare staff are expected to attend emergency calls throughout the day, and at weekends when staffing is reduced a single staff member attends emergency calls. In the future, Healthcare staff will ensure two members of staff attend all health emergency calls over the radio. Where nurses are completing tasks alone and are called to attend a Code Red or Code Blue emergency, they should request another colleague to attend by making the request over the radio.”

    Source location

    2014-0324-Response-by-NOMS
    Page 1 · response
    Published 14 July 2014

    Open published response

  8. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thomas George 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

    Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

    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

    Difficulties in internal communication during evolving emergencies

    Wider context from the report

    “(4) The expert recommends a “stress testing of ward management” through a clinical scenario simulation of emergencies within ward areas. This could also test how to improve communication during times of evolving emergencies. Given the difficulties in internal communication as revealed by this inquest the Coroner suggests this would be a valuable exercise. ”

    Source location

    Thomas George Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Manchester North

    AI-generated summary

    Mark Darren Bartholomew · 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

    Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.

    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 essential patient and emergency-equipment information to external emergency services

    Wider context from the report

    “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:- • The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available. • Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest. • Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust. ”

    Source location

    Mark Darren Bartholomew · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    Rajesh Parkash · 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

    Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.

    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

    Inadequate communications between the control room and ambulance personnel answering a call

    Wider context from the report

    “6. Action is required to improve communications between the control room and the personnel within an ambulance that is answering a call. ”

    Source location

    Rajesh Parkash · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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