19 Nov 2021 Robert Ellery · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Cardiff Prison
Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
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Cardiff Prison
Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
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AI-generated summary
Robert Ellery · 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
Robert Ellery was found ████████ in his prison cell on 31 October 2016. The report identified a 19-minute delay in informing the ambulance service and no direct communication method between ambulance call-centre staff and the prison staff providing basic life support. These issues delayed information sharing and impeded the provision of resuscitation guidance, giving rise to concerns about risks to other deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support
Wider context from the report “(2) There was no method of communication to allow the Ambulance Service call centre staff to communicate directly with the nurse and officers who were providing basic life support to Mr Ellery. This delayed the relaying of specific information with respect to Mr Ellery’s condition by the prison to the Welsh Ambulance Service . It also impeded the ability of the ambulance service operator to provide guidance to those attempting to resuscitate Mr Ellery . This may affect the use of a defibrillator. In circumstances where not all prison staff are trained in the provision of CPR, it might also prevent the ambulance service operator providing instruction to first responders, or reduce the effectiveness of the same .
” Source location Robert Ellery · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
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6 Sep 2021 Glenda May Logsdail · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Inhibitory hierarchical structure preventing staff from speaking up during emergencies View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Glenda May Logsdail · 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
Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inhibitory hierarchical structure preventing staff from speaking up during emergencies
Wider context from the report “(5) There was evidence of an inhibitory hierarchical structure which prevented others shouting out . This is despite the fact that I found Dr ████████ to be a mild mannered, gentle and reflective witness.
” Source location Glenda May Logsdail · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.
Verbatim wording from the response “Your report highlights the critical importance of human factors in safe anaesthetic practice. Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. Regular, multidisciplinary team training is one of the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we will:” Source location 2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with stakeholders to highlight the need for sufficient theatre-team time for essential emergency-drill training.
Verbatim wording from the response “Your report highlights the critical importance of human factors in safe anaesthetic practice. Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. Regular, multidisciplinary team training is one of the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we will:” Source location 2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote and embed the Human Factors guidance for Anaesthesia recommendations in practice.
Verbatim wording from the response “• In January 2022, the Association and the Difficult Airway Society launched their Human Factors guidance for Anaesthesia. We will work together to promote and embed the recommendations from this guidance in practice.” Source location 2021-0295 - Response from Royal College of Anaesthetists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for delivering emergency simulation and team-based training, subject to available resources and clinical trainer time.
Verbatim wording from the response “In relation to your concerns about multi-disciplinary team working in an emergency situation, you may wish to note that specific simulation-based training for emergency skills and team-based drills in specialised areas of clinical practice, such as the operating theatre, is the responsibility of, and delivered by, individual NHS trusts, based on the” Source location 2021-0295-Response-from-Department-of-Health-Social-Care_Published
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5 May 2021 Richard James Ormond · Prevention of Future Deaths report Worcestershire
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Concerns raised 2
Failure to provide WMAS with critical patient-condition information promptly during emergencies View source Failure of prison and healthcare staff to recognize the need to update WMAS with critical patient-condition information View source
Linked responses
HM Prison and Probation Service Practice Plus Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
HM Prison and Probation Service
Review and update local emergency-incident policies and protocols, republish them, and issue Governor’s notices reinforcing information-sharing expectations.
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HM Prison and Probation Service
Create an Emergency Control Room checklist specifying vital ambulance-service information and follow-up questions for ongoing incident updates.
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HM Prison and Probation Service
Instruct custodial managers to communicate concise, accurate prisoner-condition reports at the earliest opportunity and issue notices describing required information.
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HM Prison and Probation Service
Amend Prison Service Instruction 03/2013 to clarify requirements for providing emergency-condition information to control rooms.
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HM Prison and Probation Service
Issue the revised emergency-response instruction, pocket cards, and control-room posters reminding staff of ambulance-service information requirements.
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Practice Plus Group
Jointly review ambulance-call information requirements with WMAS.
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Practice Plus Group
Write a new ambulance-calling process based on patient-specific information requirements.
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Practice Plus Group
Provide prison staff with guidance on communicating relevant patient information to ambulance dispatch teams.
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Practice Plus Group
Disseminate a Purple Alert across healthcare sites requiring escalation systems for deteriorating patients, particularly those requiring CPR.
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AI-generated summary
Richard James Ormond · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard James Ormond, who had a history of substance misuse while in prison, was found in his cell at HMP Long Lartin in a drug-related cardiac arrest and was declared deceased later that day at hospital. The inquest heard that critical information that he was not breathing and required CPR was not passed to the ambulance service for at least nine minutes, delaying the highest-category emergency response. Concern was raised that prison and healthcare staff might not recognise the need to provide such critical updates in similar circumstances.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide WMAS with critical patient-condition information promptly during emergencies
Wider context from the report “1) During the course of the inquest I heard evidence that:
(a) Pursuant to an agreement between HM Prison Service and West Midlands Ambulance Service (WMAS):
(i) When a Code Blue or Code Red emergency is phoned through to WMAS by a prison, and no answer can be given by the prison control room to the questions “is the patient conscious?” and “is the patient breathing?”, then without further information a Category 2 response will be generated (i.e. average attendance time of c.18 minutes );
(ii) Should further information be relayed to WMAS by the prison control room that the patient is either in cardiac arrest or peri-arrest, or not breathing, or fitting, or choking, or that CPR is being administered, WMAS will upgrade the response to Category 1 (i.e. average attendance time of 7 minutes).
(b) In Mr. Ormond’s case:
(i) It was immediately apparent to prison officers who found Mr. Ormond in his cell that he was unresponsive and required CPR. When healthcare staff responded to the Code Blue call which went out over the radio, and attended the cell a short time later, they found those officers already giving Mr. Ormond CPR;
(ii) The prison control room initially informed WMAS that this was a Code Blue emergency, but were unable to say whether Mr. Ormond was conscious or breathing. The call was therefore given a Category 2 status;
(iii) There was then a delay of at least 9 minutes before the prison control room provided WMAS with information that Mr. Ormond was not breathing and was requiring CPR , at which point WMAS upgraded the response to Category 1;
(iv) In a Safer Custody Learning Bulletin issued in December 2016 to all prison staff, entitled “The Importance of Immediate Emergency Response”, the instruction was given to “Ensure that information on the condition of the patient is passed to the control room as soon as possible so that the ambulance service can be updated.”
(v) The 9 minute delay referred to at (iii) above occurred despite prison officers and healthcare staff who first attended the scene having radios, and therefore being in a position to share the control room the information that Mr. Ormond was not breathing and required CPR.
2) The failure to provide WMAS with critical information about Mr. Ormond’s condition , which would have resulted in the call being given the highest category of emergency response, did not appear to have been recognized by either HM Prison Service or Practice Plus Group until this inquest hearing. In the circumstances, there is concern that members of the prison and healthcare staff at HMP Long Lartin will not recognize the need to update WMAS with critical information about a patient’s condition in similar circumstances.
” Source location Richard James Ormond · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of prison and healthcare staff to recognize the need to update WMAS with critical patient-condition information
Wider context from the report “1) During the course of the inquest I heard evidence that:
(a) Pursuant to an agreement between HM Prison Service and West Midlands Ambulance Service (WMAS):
(i) When a Code Blue or Code Red emergency is phoned through to WMAS by a prison, and no answer can be given by the prison control room to the questions “is the patient conscious?” and “is the patient breathing?”, then without further information a Category 2 response will be generated (i.e. average attendance time of c.18 minutes );
(ii) Should further information be relayed to WMAS by the prison control room that the patient is either in cardiac arrest or peri-arrest, or not breathing, or fitting, or choking, or that CPR is being administered, WMAS will upgrade the response to Category 1 (i.e. average attendance time of 7 minutes).
(b) In Mr. Ormond’s case:
(i) It was immediately apparent to prison officers who found Mr. Ormond in his cell that he was unresponsive and required CPR. When healthcare staff responded to the Code Blue call which went out over the radio, and attended the cell a short time later, they found those officers already giving Mr. Ormond CPR;
(ii) The prison control room initially informed WMAS that this was a Code Blue emergency, but were unable to say whether Mr. Ormond was conscious or breathing. The call was therefore given a Category 2 status;
(iii) There was then a delay of at least 9 minutes before the prison control room provided WMAS with information that Mr. Ormond was not breathing and was requiring CPR, at which point WMAS upgraded the response to Category 1;
(iv) In a Safer Custody Learning Bulletin issued in December 2016 to all prison staff, entitled “The Importance of Immediate Emergency Response”, the instruction was given to “Ensure that information on the condition of the patient is passed to the control room as soon as possible so that the ambulance service can be updated.”
(v) The 9 minute delay referred to at (iii) above occurred despite prison officers and healthcare staff who first attended the scene having radios, and therefore being in a position to share the control room the information that Mr. Ormond was not breathing and required CPR.
2) The failure to provide WMAS with critical information about Mr. Ormond’s condition, which would have resulted in the call being given the highest category of emergency response, did not appear to have been recognized by either HM Prison Service or Practice Plus Group until this inquest hearing . In the circumstances, there is concern that members of the prison and healthcare staff at HMP Long Lartin will not recognize the need to update WMAS with critical information about a patient’s condition in similar circumstances.
” Source location Richard James Ormond · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update local emergency-incident policies and protocols, republish them, and issue Governor’s notices reinforcing information-sharing expectations.
Verbatim wording from the response “After the inquest, the Governor of HMP Long Lartin undertook a review of all local policies, instructions and protocols relating to emergency incidents to ensure that they conveyed the importance of updating the ECR on a prisoner’s condition as soon as possible and passing this on to the responding ambulance service without delay. All local policies have now been updated and republished, and Governor’s notices have been issued to ensure that all staff are aware of the expectation that they should provide this information and keep in touch with the ECR during an emergency incident.” Source location 2021-0139-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create an Emergency Control Room checklist specifying vital ambulance-service information and follow-up questions for ongoing incident updates.
Verbatim wording from the response “In addition to this, a checklist has been created for staff working in the ECR which contains the vital information required by the ambulance service. The checklist includes immediate information, such as whether or not the prisoner is breathing and if CPR is being administered. There are also some follow up questions, to which staff working in the ECR can gather responses by maintaining contact and obtaining regular updates from staff at the scene.” Source location 2021-0139-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct custodial managers to communicate concise, accurate prisoner-condition reports at the earliest opportunity and issue notices describing required information.
Verbatim wording from the response “In June 2021 an instruction was given to all custodial managers (CMs) - the staff who carry out incident scene management duties - that they must communicate a concise and” Source location 2021-0139-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend Prison Service Instruction 03/2013 to clarify requirements for providing emergency-condition information to control rooms.
Verbatim wording from the response “In light of this case, and similar cases at other prisons, we have amended the relevant Prison Service Instruction (PSI 03/2013 Emergency Response Codes) to make the requirement to provide information to the control room clearer. The revised version will shortly be issued, alongside pocket cards, and posters for use in control rooms, reminding staff of the information that is required by ambulance services when receiving an emergency call.” Source location 2021-0139-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue the revised emergency-response instruction, pocket cards, and control-room posters reminding staff of ambulance-service information requirements.
Verbatim wording from the response “In light of this case, and similar cases at other prisons, we have amended the relevant Prison Service Instruction (PSI 03/2013 Emergency Response Codes) to make the requirement to provide information to the control room clearer. The revised version will shortly be issued, alongside pocket cards, and posters for use in control rooms, reminding staff of the information that is required by ambulance services when receiving an emergency call.” Source location 2021-0139-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Jointly review ambulance-call information requirements with WMAS.
Verbatim wording from the response “Response: We understand that a process was put in place at HMP Long Lartin, which had been agreed between the West Midlands Ambulance Service (WMAS) and HMP Long Lartin. This had been circulated to prison staff in a Safer Custody Bulletin in 2016, prior to the implementation of the new ambulance response categories and before Practice Plus Group held the contract for healthcare provision at Long Lartin. Unfortunately Practice Plus were not made aware of this agreement and it has not been revisited with WMAS since the original process was agreed. We have contacted WMAS to jointly review the process and we will:” Source location 2021-0139 - Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write a new ambulance-calling process based on patient-specific information requirements.
Verbatim wording from the response “Response: We understand that a process was put in place at HMP Long Lartin, which had been agreed between the West Midlands Ambulance Service (WMAS) and HMP Long Lartin. This had been circulated to prison staff in a Safer Custody Bulletin in 2016, prior to the implementation of the new ambulance response categories and before Practice Plus Group held the contract for healthcare provision at Long Lartin. Unfortunately Practice Plus were not made aware of this agreement and it has not been revisited with WMAS since the original process was agreed. We have contacted WMAS to jointly review the process and we will:” Source location 2021-0139 - Response from Practice Plus Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide prison staff with guidance on communicating relevant patient information to ambulance dispatch teams.
Verbatim wording from the response “Response: We understand that a process was put in place at HMP Long Lartin, which had been agreed between the West Midlands Ambulance Service (WMAS) and HMP Long Lartin. This had been circulated to prison staff in a Safer Custody Bulletin in 2016, prior to the implementation of the new ambulance response categories and before Practice Plus Group held the contract for healthcare provision at Long Lartin. Unfortunately Practice Plus were not made aware of this agreement and it has not been revisited with WMAS since the original process was agreed. We have contacted WMAS to jointly review the process and we will:” Source location 2021-0139 - Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate a Purple Alert across healthcare sites requiring escalation systems for deteriorating patients, particularly those requiring CPR.
Verbatim wording from the response “Response: Practice Plus Group has a robust process (our Purple Alert system) for sharing important patient safety information across all prison sites within which we provide healthcare services. We can confirm that in April 2021, as soon as we became aware of this issue, a Purple Alert was disseminated across all sites to request that immediate action be taken to ensure that systems are in place to escalate deteriorating patients, particularly those who require CPR, to enable an appropriate ambulance response time.” Source location 2021-0139 - Response from Practice Plus Group
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Concerns raised 1
Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Hart Care Limited
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
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AI-generated summary
Clara Ellen Freeman · 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
Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency
Wider context from the report “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition .
It is requested that the training for care and nursing staff be reviewed to consider;
a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency
b) Accurate recording of medical information including vital signs
c) Awareness of the risks of medical complications following falls and long lies.
” Source location Clara Ellen Freeman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
Verbatim wording from the response “In accordance with the Regulation 28 Report to Prevent Future Deaths dated 26th March 2021, I write to confirm that we have taken action and all our staff members who are in charge of shifts in the home have attended First Aid Training on the 11th and 13th May 2021 in addition to the mandatory training programme we have in place.” Source location 2021-0085-Response-from-Hart-Care-Redacted
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24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure of Emergency Services to use mutually understood control-room terminology View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Douglas Paul Oak · 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
On 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” Source location Douglas Paul Oak · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Verbatim wording from the response “The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.” Source location 2019-0352-Response-by-College-of-Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue national work with emergency-service partners to improve consistency in ABD recognition and prioritisation.
Verbatim wording from the response “The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues with their local emergency service providers.” Source location 2019-0352-Response-by-College-of-Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There are seldom misunderstandings about response urgency because call handlers seek details and ambulance triage is based on clinical presentation.
Verbatim wording from the response “We accept that clarity in language is important when communicating across emergency services. Contact Management officers and staff are trained to enquire and probe for additional details when receiving calls and our experience leads us to believe that there are seldom misunderstandings in relation to the importance of response required. It is however recognised that the ambulance service triage each call based on the description of the medical presentation of the patient not on the type of illness being stated.” Source location 2019-0352-Response-by-College-of-Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
Verbatim wording from the response “The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues with their local emergency service providers.” Source location 2019-0352-Response-by-College-of-Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lack of common terminology or use of “on the hurry up” is not considered the cause of the ambulance response problem.
Verbatim wording from the response “v) We do not believe that the absence of common terminology or the use of the term ‘on the hurry up’ was the issue. The ambulance response to all incidents are prioritised on information based on the patients presenting condition. Therefore it is essential to obtain appropriate information about the patient’s condition, and that this is passed from police to ambulance services in order to correctly prioritise the response and this will be our principal focus of ongoing work with the police. Once the new guidance on ABD has been ratified and issued and the trial in Yorkshire as described in point ii above has been completed, we will continue to discuss this in our work with the police to improve communications between ambulance and police control rooms.” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
Open published response
14 Oct 2019 César Cuauhtémoc González Barrón · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to communicate the nature of an emergency when summoning first aiders View source Failure to provide a competent handover to ambulance services View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
César Cuauhtémoc González Barrón · 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
César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate the nature of an emergency when summoning first aiders
Wider context from the report “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened . She had no understanding of the nature of the emergency .
The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going.
The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it.
” Source location César Cuauhtémoc González Barrón · 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 provide a competent handover to ambulance services
Wider context from the report “8. The handover to LAS was confused, with mixed messages as to whether the automated external defibrillator had delivered a shock or not. No person took charge of a competent handover to LAS.
” Source location César Cuauhtémoc González Barrón · Prevention of Future Deaths report
Open source report
14 Aug 2019 Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Lack of provision to provide updates to other emergency services during significant ambulance delays View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Gladys Esme FURNIVAL (known as Esme FURNIVAL) · 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
Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.
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 provision to provide updates to other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them .
” Source location Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report
Open source report
17 Jun 2019 Oliver Hall · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure to inform medical professionals of ambulance delays of 39 minutes or less View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Association of Ambulance Chief Executives
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AI-generated summary
Oliver Hall · 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
Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to inform medical professionals of ambulance delays of 39 minutes or less
Wider context from the report “2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call.
It was identified, that in a septicaemia case similar to Oliver’s (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2.
As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases).
Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less .
Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidly deteriorated.
As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating .
” Source location Oliver Hall · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Call takers cannot provide accurate expected arrival times because emergency responses are fluid and may be diverted to more urgent incidents.
Verbatim wording from the response “Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call taker to give accurate information regarding the expected time of arrival of a response. This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for a responding ambulance to be diverted from one emergency to another that has been assessed as more urgent or indeed for a responding ambulance to be flagged down at another incident they may be passing. For these reasons, call takers do not commit to an estimated time of arrival, rather they are asked to say ‘help is on its way and please ring back if the patient’s condition changes’.” Source location 2019-0198-response-by-Association-of-Ambulance-Chief-Executives
Open published response
24 Oct 2018 Catherine Mary GIBBON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Absence of immediate poolside telephone access for summoning medical assistance View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Catherine Mary GIBBON · 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
Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.
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 Absence of immediate poolside telephone access for summoning medical assistance
Wider context from the report “7. There was no landline at poolside that could be used to call an ambulance in case of emergency , to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty .
” Source location Catherine Mary GIBBON · Prevention of Future Deaths report
Open source report
20 Aug 2018 Jacob Sulaiman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Inaccessibility of information about recent contacts with other services during emergency call-outs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
London Borough of Camden
Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
View source
London Borough of Camden
Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
View source
London Borough of Camden
Develop information-sharing arrangements with London Ambulance Service.
View source
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AI-generated summary
Jacob Sulaiman · 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
Jacob Sulaiman died at home on 8 December 2017 after a fire started in his bedroom, causing carbon monoxide poisoning. The principal concerns were that response officers did not have complete or readily accessible information about his contacts with other services, including the outcome of a paramedic visit, which may have affected the assessment and management of his mental capacity.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inaccessibility of information about recent contacts with other services during emergency call-outs
Wider context from the report “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
” Source location Jacob Sulaiman · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
Verbatim wording from the response “In preparation for this move, a new IT platform was required to support the” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
Verbatim wording from the response “This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Caroline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop information-sharing arrangements with London Ambulance Service.
Verbatim wording from the response “The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Caroline service has already made contact with LAS to begin discussions about how information could be better shared in future.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
Verbatim wording from the response “Wellbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
Verbatim wording from the response “It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Wellbeing were aware of, and coordinated the responses, whether they were remotely or in person.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.