Recurring concern

Failure to take timely escalation action when safety thresholds are breached

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First reported 27 Jan 2014•Latest report 16 Mar 2026

Definition

What this concern includes

Includes failures to initiate, progress or complete escalation when a defined safety threshold, failed contact or time limit has been reached, including escalation after repeated failed visits, breached response times or comparable triggers requiring senior review, resource allocation or welfare intervention.

Not included

Excludes the underlying safety concern, staffing shortage or clinical deterioration when no failure to escalate after a defined trigger is identified.
Excludes failures of ordinary communication or notification where no safety threshold, failed contact or breached time limit required escalation.
Excludes deficiencies confined to the substantive content of an escalation policy when the policy's operation after a trigger is not the unsafe condition.
Excludes the existing broader concern about failure to escalate patient-safety concerns to senior oversight when the assertion does not specifically identify a breached threshold, failed contact or time-based escalation trigger.

Reports: 62
Individual concerns: 65
Date range: 2014–2026
Stated actions: 84

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6

NHS England5

Barts Health NHS Trust3

Care Quality Commission3

North West Ambulance Service NHS Trust3

East Midlands Ambulance Service NHS Trust2

Essex County Council2

Essex Partnership University NHS Foundation Trust2

Manchester University NHS Foundation Trust2

South East Coast Ambulance Service NHS Foundation Trust2

University Hospitals Sussex NHS Foundation Trust2

Adbolton Hall1

Aneurin Bevan University LHB1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Bedford Prison1

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.

7 Mar2018
Inner West London
Concerns raised1
1. Failure to escalate fire-alarm activations to the fire brigade within 30 seconds
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Elizabeth Marion Griffin · 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

Mrs Elizabeth Marion Griffin, who was wheelchair bound due to advanced multiple sclerosis, was alone at home in bed when a dishwasher fire started on 14 July 2017. She activated her pendant alarm, but the responder did not recognise the smoke alarm, could not communicate effectively with her, and did not call the fire brigade; Mrs Griffin later died in hospital on 21 August 2017 from smoke inhalation injuries and bronchopneumonia. The concerns included delayed action by the dishwasher manufacturer, lack of appliance-owner registration and contact, and shortcomings in telecare arrangements, including unlinked fire alarms, responder training, communication, and escalation procedures.

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 escalate fire-alarm activations to the fire brigade within 30 seconds
Wider context from the report
“7. That telecare system operators and WWA in particular, apply the British Standards Institute requirement to call for the help of the fire brigade after 30 seconds maximum of trying to contact a client if the client’s fire alarm goes off. ”
Source location
Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
Page 4 · concerns
Open source report
27 Feb2018
Brighton and Hove
Concerns raised1
1. Failure to flag clinically significant updates for call upgrading
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Remind all call takers when to upgrade calls and seek senior guidance about NHS Pathways dispositions.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Implement the NHS Pathways update strengthening guidance for assessing consciousness levels in conscious patients.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
AI-generated summary

Kevan FUNNELL · 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

Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose 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 flag clinically significant updates for call upgrading
Wider context from the report
“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”
Source location
Kevan FUNNELL · Prevention of Future Deaths report
Page 2 · 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
Remind all call takers when to upgrade calls and seek senior guidance about NHS Pathways dispositions.

Verbatim wording from the response
“For Mr Funnell, the call taker did not seek to upgrade the call. This was human error. The manager of the Emergency Operations Centre (EOC) has used the learning from this case to remind all call takers about the circumstances to consider when upgrading a call and the need to seek senior guidance if there is any doubt about the disposition reached through NHS Pathways.”

Source location
Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024
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
Implement the NHS Pathways update strengthening guidance for assessing consciousness levels in conscious patients.

Verbatim wording from the response
“On 22 November 2017, we implemented a significant update to NHS Pathways. The new version includes amendments to the supporting information for conscious patients, in order to try and make it more robust and easier for call takers in situations like this one, to identify consciousness levels. If this updated version had been in use in October 2017 then Mr Funnell would have been classified as unconscious. The disposition would therefore have most likely been a Red 2 response with a target attendance time of 8 minutes. This demonstrates the evolving nature of the Pathways system.”

Source location
Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024
Open published response
26 Jan2018
Manchester South
Concerns raised1
1. Failure to adequately escalate urgent drainage needs to Radiology management
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs. Riaz Begum · 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

Mrs. Riaz Begum developed a bile leak and sepsis following a laparoscopic cholecystectomy, and later developed acute pancreatitis after an ERCP to repair the leak. She died on 16 July 2017 despite treatment for sepsis and multi-organ failure. Concerns included delays in CT-guided drainage and ERCP, insufficient radiology capacity, inadequate escalation, and the potential impact of consultant leave on ERCP availability.

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 adequately escalate urgent drainage needs to Radiology management
Wider context from the report
“(1) I am concerned that on the 3rd July 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary, it was not done until the 5th July 2017. The evidence I have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure. (2) I am also concerned that after the 3rd July the need for the drainage to take place was not adequately escalated to Radiology management when ████████ indicated he could not undertake the procedure within the timescale requested. When the matter was escalated on the 5th July, ████████ had to be essentially told to do the procedure and offered an additional professional fee. I consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone being treated for sepsis and possible bile leak puts at risk. ”
Source location
Mrs. Riaz Begum · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Nov2017
Sunderland
Concerns raised1
1. Failure to ensure sufficiently rapid escalation to senior managers
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Escalate unsafe property-access decisions to senior operational managers for review and direct crew support.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
AI-generated summary

Darren James Powney · 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

Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.

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 ensure sufficiently rapid escalation to senior managers
Wider context from the report
“The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through. I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid. Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention. For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest. ”
Source location
Darren James Powney · 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
Escalate unsafe property-access decisions to senior operational managers for review and direct crew support.

Verbatim wording from the response
“In order to address this we have ensured that when a crew does not feel safe to proceed and access a property, without police support, based on the ‘flag’ this is then escalated to the Clinical Operation Manager or the Assistant Services Manager on duty so they may review all information available and speak directly to the crew on scene.”

Source location
2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 5 February 2018
Open published response
27 Oct2017
Manchester City
Concerns raised1
1. Lack of escalation for admission of patients requiring continued observation or review
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Assess early warning score use and escalation at the next inspection.
  Stated by Care Quality CommissionStated planned
2. Action
  Continue monitoring early warning score use and escalation through quarterly engagement with the Trust.
  Stated by Care Quality CommissionStated in progress
Respondent positions 2
1. Position
  The information currently held provides no evidence that the concerns reflect a systemic issue.
  Stated by Care Quality CommissionDisputes the concern
1. Position
  No further regulatory action is considered necessary regarding this matter based on the information currently held.
  Stated by Care Quality CommissionNo action considered necessary
AI-generated summary

Stephen George Coulson · 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 George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.

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 escalation for admission of patients requiring continued observation or review
Wider context from the report
“2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge ”
Source location
Stephen George Coulson · Prevention of Future Deaths report
Page 2 · 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
Assess early warning score use and escalation at the next inspection.

Verbatim wording from the response
“That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.”

Source location
2017-0307-Response-by-CQC
Page 3 · response
Published 28 November 2017
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
Continue monitoring early warning score use and escalation through quarterly engagement with the Trust.

Verbatim wording from the response
“That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.”

Source location
2017-0307-Response-by-CQC
Page 3 · response
Published 28 November 2017
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 information currently held provides no evidence that the concerns reflect a systemic issue.

Verbatim wording from the response
“In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.”

Source location
2017-0307-Response-by-CQC
Page 3 · response
Published 28 November 2017
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
No further regulatory action is considered necessary regarding this matter based on the information currently held.

Verbatim wording from the response
“In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.”

Source location
2017-0307-Response-by-CQC
Page 3 · response
Published 28 November 2017
Open published response
16 Oct2017
Wiltshire and Swindon
Concerns raised1
1. Delays and unclear responsibility for timely clinician escalation from care plans
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.
  Stated by Great Western Hospitals NHS Foundation TrustStated planned
2. Action
  Update simulation training to emphasise clear communication and delegation of responsibility.
  Stated by Great Western Hospitals NHS Foundation TrustStated planned
3. Action
  Review and update mandatory Adult Basic Life Support training with emergency and non-emergency delegation scenarios and documentation requirements.
  Stated by Great Western Hospitals NHS Foundation TrustStated planned
1. Action
  Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.
  Stated by Great Western Hospitals NHS Foundation TrustStated planned
AI-generated summary

Jeremy Michael Holt · 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

Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.

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 unclear responsibility for timely clinician escalation from care plans
Wider context from the report
“1. Expectations of F1/F2 doctors – personally I have no experience of training or being involved in the training of F1/F2 doctors and my only experience in respect of which I do not see a fundamental dissimilarity is in relation to trainee lawyers or in particular training solicitors in respect of whom I have been involved in their training during my professional career. F1/F2’s when appointed are given a provisional licence to practice at the end of their medical degree. Trainee solicitors are again allowed to work under supervision following the completion of their professional examinations which for example can be a degree combined with a post graduate legal practice course. My experience in relation to trainee solicitors is that the expectations of what they realistically can do is at a low level and having heard from ████████ from whom I was told that it is not fundamentally different in respect of F1/F2 doctors. The Great Western Hospital of course is a teaching hospital and therefore in relation to the training of doctors it is often, I imagine, imperative that what may seem obvious to you or I perhaps needs to be spelled out to those trainees who may be entering the working environment in their chosen career area for the very first time. In relation to Dr Marshall's case I was concerned that the evidence revealed that ████████ had not contacted ████████ until the bleeped him at 0513 despite the care plan in relation to a seriously ill patient who at the time was peripherally shutting down in respect of which both ████████ and ████████ had recognised the seriousness of the condition as to why ████████ was not contacted sooner. There had been a 3 point increase in his NEWS score yet there appeared to be a delay in contacting ████████ to a degree and significant delay in contacting ████████. No instruction had been given to nursing staff to bleep the relevant doctors and I am concerned as to whether or not in respect of all doctors that the point needs to be emphasised that whoever records the care plan on the notes at doctor level should have the responsibility of bleeping another clinician in a timely fashion unless the notes clearly indicate that that responsibility has been given to somebody else and then the notes to identify when and to whom that instruction was given. ”
Source location
Jeremy Michael Holt · Prevention of Future Deaths report
Page 2 · 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
Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.

Verbatim wording from the response
“The Trust has considered your view and is of the belief there is no single solution to this. The omissions most likely stemmed from human factors rather than a system failing. Therefore a multidisciplinary approach is being taken strengthening personal accountability including updates to a handbook, simulation training and Adult Basic Life Support training.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 2 · response
Published 18 December 2017
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 simulation training to emphasise clear communication and delegation of responsibility.

Verbatim wording from the response
“The Trust also has plans to update simulation training and the Adult Basic Life Support training. Simulation training consists of interactive training sessions relating to real life clinical situations. The Trust plans to incorporate the importance of clarity of communication (including delegating responsibility for tasks) into these sessions. Simulation training sessions which have already been held, have been found to be highly effective in developing the skills of staff.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 2 · response
Published 18 December 2017
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 and update mandatory Adult Basic Life Support training with emergency and non-emergency delegation scenarios and documentation requirements.

Verbatim wording from the response
“The Adult Basic Life Support is annual mandatory face to face training for clinical staff. There is a plan to review the training provided and to update this to include scenario training on what to do in an emergency situation specifically in relation to the delegation of tasks. There is a plan to also include a section on what to do in a non-emergency situation and the importance of documenting delegation details.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 2 · response
Published 18 December 2017
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
Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.

Verbatim wording from the response
“In the New Year the Trust will be installing an electronic observations IT system. For this the Trust is developing clear algorithms to enable automatic escalation to the doctors, this will be on a loop so if for example the F2 doctors do not respond, this will be escalated to the registrars and will continue through the doctor ranks up to Consultant until someone responds to the escalation alert. I have enclosed the high level roll out plan, you will see we aim to have electronic observations implemented Trust wide by May 2018.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
Open published response
21 Sep2017
Surrey
Concerns raised1
1. Failure to take further action when follow-up contact after an unanswered alarm call fails
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Derek Clifford Dudley · 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

Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.

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 take further action when follow-up contact after an unanswered alarm call fails
Wider context from the report
“The operator attempted to contact Mr Dudley by telephone again 1.5 hours later, which ████████ again stated was in breach of Telecare’s policy, but there was no answer and no further action was taken. ”
Source location
Derek Clifford Dudley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Apr2017
South Yorkshire (Eastern)
Concerns raised1
1. Failure to escalate or allocate resources when time scales are breached
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Implement a CAD Call Alert process that highlights unallocated incidents to dispatch management.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
2. Action
  Identify the possibility of changing the system to flag incomplete resource checks within the target timeframe.
  Stated by Yorkshire Ambulance Service NHS TrustStated in progress
3. Action
  Introduce a CAD minus-minute indicator showing how long each incident has remained without an allocated resource.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
1. Action
  Deliver EOC training away days covering role responsibilities, incident review, revision, allocation and timely prioritisation of high-priority calls.
  Stated by Yorkshire Ambulance Service NHS TrustStated planned
2. Action
  Issue an Operational Alert reiterating the need to allocate the most appropriate available resource without delay.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
3. Action
  Use monthly one-to-one performance information to monitor dispatchers’ resourcing performance against targets.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
AI-generated summary

Barry Stuart Hodges · 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

Barry Stuart Hodges, a 69-year-old man, collapsed with chest pains at a tennis club on 23 August 2016 and died after being transferred to hospital following cardiac arrest. The report identified failures to follow ambulance dispatch and resource-review protocols, insufficient safety-netting and apparent gaps in staff knowledge or training, with available resources not allocated and escalation not undertaken when timescales were breached.

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 escalate or allocate resources when time scales are breached
Wider context from the report
“(3) Time scales were breached without further action ie. escalation to Senior Management, Clinicians or allocation of resources. ”
Source location
Barry Stuart Hodges · Prevention of Future Deaths report
Page 2 · 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
Implement a CAD Call Alert process that highlights unallocated incidents to dispatch management.

Verbatim wording from the response
“There is now a process in place within Emergency Operations Centre (EOC) whereby a “Call Alert” is highlighted on the Dispatcher’s, Team Leader’s and Duty Manager’s computer automated dispatch (CAD) screen. This highlights when an incident has not been allocated. We are also in the process of identifying the possibility of a system change to identify when a resource check has not been completed within the target timeframe. The introduction of these systems enables the direct managers of the Dispatchers to be made aware of any live incidents that have not been allocated a resource during the incident.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 2 · response
Published 5 June 2017
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
Identify the possibility of changing the system to flag incomplete resource checks within the target timeframe.

Verbatim wording from the response
“There is now a process in place within Emergency Operations Centre (EOC) whereby a “Call Alert” is highlighted on the Dispatcher’s, Team Leader’s and Duty Manager’s computer automated dispatch (CAD) screen. This highlights when an incident has not been allocated. We are also in the process of identifying the possibility of a system change to identify when a resource check has not been completed within the target timeframe. The introduction of these systems enables the direct managers of the Dispatchers to be made aware of any live incidents that have not been allocated a resource during the incident.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 2 · response
Published 5 June 2017
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
Introduce a CAD minus-minute indicator showing how long each incident has remained without an allocated resource.

Verbatim wording from the response
“We have also further introduced a systems change to assist the EOC management teams with identifying details that have not had a resource allocated within time scales. The system now shows a “minus minute” indicator on the Dispatcher’s, Team Leader’s and Duty Manager’s CAD screen which indicates for each incident how many minutes have passed without a resource being allocated. This enables the Team Leader or Duty Manager the ability to monitor all incidents to ensure they are compliant with timescales.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 2 · response
Published 5 June 2017
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 EOC training away days covering role responsibilities, incident review, revision, allocation and timely prioritisation of high-priority calls.

Verbatim wording from the response
“The Trust has intense training away days for all EOC staff set up to take place throughout the summer months. Part of these training away days will include reiterating to all EOC staff the core elements of their role, especially around the fundamental aspects of review, revise and allocate with emphasis on not delaying allocation to high priority calls.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 3 · response
Published 5 June 2017
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
Issue an Operational Alert reiterating the need to allocate the most appropriate available resource without delay.

Verbatim wording from the response
“The attached (Appendix 1) Operational Alert was produced on 24 April this year to further reiterate to staff the need to allocate the most appropriate resource available without delay.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 3 · response
Published 5 June 2017
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
Use monthly one-to-one performance information to monitor dispatchers’ resourcing performance against targets.

Verbatim wording from the response
“EOC staff members have monthly 1:1’s at which the Trust are now able to produce personal performance information, this enables the manager to review whether the dispatcher is meeting appropriate targets, this includes information regarding resourcing of incidents. If it is found there are areas which require improvement the Trust allocates a team champion to sit with the staff member to supervise their work until it is felt that the staff member is performing satisfactorily.”

Source location
2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Page 3 · response
Published 5 June 2017
Open published response
20 Apr2017
South Wales Central
Concerns raised1
1. Failure to appropriately escalate care in response to deteriorating NEWS scores
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Harold Mullins · 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

Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

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 appropriately escalate care in response to deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Source location
Harold Mullins · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Mar2017
Inner North London
Concerns raised2
1. Failure to advise callers to contact emergency services during urgent mental health crises
2. Failure to escalate urgent crisis calls internally to expedite home visits
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Increase HTT flexibility to bring forward visits for service users whose mental health deteriorates between scheduled visits.
  Stated by East London NHS Foundation TrustStated planned
3. Action
  Reconfigure the HTT to provide 24-hour face-to-face contact when required and an enhanced urgent response service.
  Stated by East London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Directing callers to Police and Ambulance services is considered an appropriate and robust response in emergencies.
  Stated by East London NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Mariana Hungria Bayam Veiga PINTO · 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

Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.

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 advise callers to contact emergency services during urgent mental health crises
Wider context from the report
“3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could. When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm. After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward. The nurse did not ring the emergency services himself in case ████████ had been unable to make the call. ”
Source location
Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report
Page 2 · 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 escalate urgent crisis calls internally to expedite home visits
Wider context from the report
“3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could. When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm. After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward. The nurse did not ring the emergency services himself in case ████████ had been unable to make the call. ”
Source location
Mariana Hungria Bayam Veiga PINTO · 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
Implement and provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.

Verbatim wording from the response
“It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.”

Source location
response-Pinto
Page 2 · response
Published 5 April 2017
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
Increase HTT flexibility to bring forward visits for service users whose mental health deteriorates between scheduled visits.

Verbatim wording from the response
“I understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday. This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend.”

Source location
response-Pinto
Page 3 · response
Published 5 April 2017
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
Reconfigure the HTT to provide 24-hour face-to-face contact when required and an enhanced urgent response service.

Verbatim wording from the response
“I understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday. This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend.”

Source location
response-Pinto
Page 3 · response
Published 5 April 2017
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
Directing callers to Police and Ambulance services is considered an appropriate and robust response in emergencies.

Verbatim wording from the response
“In relation to your final point regarding the handling of the call made by Mr Parra-Braun on the afternoon of 16th October it is important to confirm that in an emergency situation advice to contact Police and Ambulance is an appropriate and robust response. I believe that your specific concern related to what support the HTT could have provided in the interim, for example the member of staff attempting to speak to the service user to deescalate the situation and/or personally contacting the emergency services.”

Source location
response-Pinto
Page 2 · response
Published 5 April 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to escalate fire-alarm activations to the fire brigade within 30 seconds

Concerns raised1

Failure to flag clinically significant updates for call upgrading

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to adequately escalate urgent drainage needs to Radiology management

Concerns raised1

Failure to ensure sufficiently rapid escalation to senior managers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Lack of escalation for admission of patients requiring continued observation or review

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays and unclear responsibility for timely clinician escalation from care plans

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to take further action when follow-up contact after an unanswered alarm call fails

Concerns raised1

Failure to escalate or allocate resources when time scales are breached

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Actions described in response 2

Actions described in response 1

Actions described in response 2

Respondent positions 2

Actions described in response 4

Actions described in response 6