Recurring concern

Ineffective communication during medical emergencies

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First reported 1 Oct 2013•Latest report 26 May 2026

Definition

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.

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
42

Distinct published reports

Individual concerns
49

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
61

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care11
HM Prison and Probation Service5
Association of Ambulance Chief Executives3
Ministry of Justice3
NHS England3
Home Office2
London Ambulance Service NHS Trust2
National Institute for Health and Care Excellence2
South Central Ambulance Service NHS Foundation Trust2
Boldmere Court Care Home1
Bourne Leisure Limited1
Capita Business Services Ltd1
Capita PLC1
Cardiff Prison1
Care Quality Commission1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Amy Friar · 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

    Amy Friar was found partially suspended by a ligature in her cell at HMP Downview on 30 March 2011 and was already dead when found. The inquest concluded that she took her own life, with hanging recorded as the cause of death. The report raised concern that differing emergency codes across prisons could cause confusion and delay assistance in other circumstances, although this did not contribute to Ms Friar’s death.

    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 a universal emergency code across the prison estate

    Wider context from the report

    “The prison officer who sounded the alarm had recently arrived at HMP Downview from a different prison. That prison used different emergency codes to those which were used at HM Downview. As a consequence, initially the wrong code was called and there was confusion over the nature of the incident. In this particular incident that confusion did not impact upon or contribute to Ms Friar’s death. However, the lack of a universal emergency code across the prison estate has the potential to cause confusion and which, in different circumstances, may cause a delay in assistance being received and thereby lead to circumstances that create a risk of other deaths occurring in the future. Evidence was heard that in January 2013 a new PSI (PSI 03/2013) established two different sets of emergency codes, one colour and one numeric. Code Blue being for the more serious breathing/collapse incidents and Code Red being for less serious blood/burns injuries. The equivalent numeric codes were One for breathing/collapse and Two for blood/burns. In my opinion retaining two different codes does not remove the potential for confusion where prison staff move between prisons, as referred to above. Further, I heard evidence that at HMP Downview the numeric codes are used and that a card has been developed which is of a size to fit at the rear of the prison officers identity card, meaning that it is with the prison officer at all times whilst they are at work. That card sets out in clear terms what the emergency codes are and the situations to which they apply. In addition posters have been put up in a large number of areas around the prison detailing the same information. Consideration might be given to extending this example of best practice across the whole prison estate. ”

    Source location

    Amy Friar · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Oxfordshire

    AI-generated summary

    DAVID LESLIE SELMAN · 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 Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause of death.

    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 in communication between police and the ambulance control room

    Wider context from the report

    “5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back. 5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem. ”

    Source location

    DAVID LESLIE SELMAN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026