Recurring concern

Failure to call an ambulance promptly when emergency assistance is required

First to latest report 1 Aug 2013 — 27 Jan 2026

Reports that mention this concern
37
Times this concern has been raised
42
Stated actions linked to this concern
46

What this concern includes

Includes failures of the dedicated process for recognising the need for emergency ambulance assistance and initiating the call without avoidable delay, including delays caused by repeat observations, seeking managerial approval, uncertainty about the threshold for calling, or prioritising other tasks.

What is not included
  • Excludes delays in ambulance attendance, dispatch, travel or hospital handover after the ambulance has been called.
  • Excludes emergency call-handling, triage or ambulance-resource failures where the issue is not the prompt initiation of the ambulance call.
  • Excludes generic emergency-response delays or failures that do not specifically concern calling an ambulance.
  • Excludes failures to provide advice or care while awaiting an ambulance when the ambulance call itself was made promptly.

Reports and published responses 37 reports

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

  1. Inner South London

    AI-generated summary

    James O’Brien · 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

    James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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 calling an ambulance

    Wider context from the report

    “(3) There was a delay of about 6 minutes in calling the ambulance. ”

    Source location

    James O’Brien · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 2017

    Open published response

  2. Manchester South

    AI-generated summary

    Malcolm Bennett · 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

    Malcolm Bennett, a resident of a care establishment, sustained injuries in falls and altercations with other residents. After an alleged assault on 15 December 2015, he was taken to hospital several hours later and died the following day from a head injury; the principal concern was the delay in arranging hospital treatment despite his care plan.

    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 arranging emergency hospital assessment and transport after suspected significant injury

    Wider context from the report

    “In the care Plan for this person, it clearly indicated that in the event of any significant injury he should be taken as expeditiously as possible to the Emergency Dept. of the hospital. Clearly this was not done, in that the staff left him knowing that he had apparently been hit by someone and he might well be injured, and they did not call for an ambulance for another three hours. In the light of his cause of death, this delay might have been contributory. ”

    Source location

    Malcolm Bennett · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.

    Verbatim wording from the response

    “1. All Home Managers in each of Borough Care's care homes were instructed to update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant, with an instruction to ring 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury. Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated.”

    Source location

    2016-0232-Response-by-Borough-Care
    Page 1 · response
    Published 22 June 2016

    Open published response

  3. South London

    AI-generated summary

    Ratidzai Kudkawashe SANGARE · 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 Ratidzai Kudkawashe Sangare was a detained patient who was found unresponsive on the floor of her room on the morning of her planned discharge, with a dressing gown belt around her neck. The inquest concluded that she died from ligature compression of the neck, between 5.15 and 8.28 a.m. on Millbrook Ward. Concerns included delays in recognising the need for resuscitation and emergency assistance, delayed response to the alarm, and limited telephone access for agency staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to recognise when immediate cardiopulmonary resuscitation, alarm activation and ambulance summoning are required

    Wider context from the report

    “(1) Healthcare staff were unaware or did not recognise that Mrs Sangare's condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance ”

    Source location

    Ratidzai Kudkawashe SANGARE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. West Yorkshire Eastern

    AI-generated summary

    Paul David Whitehead · 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

    Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

    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 calling an Ambulance after an incident

    Wider context from the report

    “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty. (2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager. (3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation. (4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes. These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur. Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty. ”

    Source location

    Paul David Whitehead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.

    Verbatim wording from the response

    “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    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 the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.

    Verbatim wording from the response

    “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    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 first aider correctly prioritised the emergency-services call before contacting the company Health and Safety manager.

    Verbatim wording from the response

    “2) Mixed evidence about whether the designated first aider prioritised actions correctly and called the Ambulance or the company Health & Safety manager first.”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · 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

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    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 uncertainty in calling an emergency ambulance and using the code blue call

    Wider context from the report

    “8. The evidence indicated that there was a delay (albeit a short one) in either healthcare or discipline staff calling for an emergency ambulance to attend and/or whether code blue as an expression was used. Other inquests have clearly identified issues at the establishment about the calling of an emergency ambulance. ”

    Source location

    Kevin Anthony Forster · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.

    Verbatim wording from the response

    “Following the death of Mr Kevin Anthony Forster on 14th September 2015, while in custody at HMP Durham, the following actions have already been taken by the prison to ensure all staff have a full understanding of the Emergency Code Protocol which covers the use of Codes Blue and Red. These steps were taken prior to the Inquest occurring and were in response to the concerns made by the Prison Probation Ombudsman Report and also from the prison’s own learning exercise that was undertaken following this death.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 2015

    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 pocket-sized Emergency Code Protocol cards to staff.

    Verbatim wording from the response

    “All staff have been issued with pocket sized cards explaining the protocol.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 2015

    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

    Display Emergency Code Protocol posters prominently in all residential areas.

    Verbatim wording from the response

    “All residential areas which are the wings on which prisoners live have displayed the protocol in bold colours in prominent places which are A4 size. These posters can be located in the wing main offices which everyone attending a wing must report to.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 2015

    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

    Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.

    Verbatim wording from the response

    “A Governors Notice to Staff has been issued to ensure that all new staff either directly or non-directly employed attend the Safer Custody department and receive a full explanation of the Emergency Code Protocol”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.

    Verbatim wording from the response

    “The Emergency Protocol has been an agenda item on monthly team meetings with staff and the protocol fully explained. It is also discussed at the Safer Prisons meeting as part of a wider discussion on deaths in custody. The Deputy Governor has addressed the emergency protocol issue with all functional heads at meetings and this has been cascaded to staff by line managers.”

    Source location

    2015-0453-Response2
    Page 2 · response
    Published 28 October 2015

    Open published response

  6. Manchester West

    AI-generated summary

    Christopher John Smith · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to immediately establish responsibility for calling an ambulance

    Wider context from the report

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

    Source location

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

    Open source report

  7. Manchester South

    AI-generated summary

    Kathleen Eaton · 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

    Kathleen Eaton fell in her bedroom on 26 January 2015 and was lifted using a blow-up ‘hoist’ before being left awaiting her regular carers. She was later taken to hospital, where she was found to have damage to and around her brain; the inquest recorded subdural and subarachnoid haemorrhage, recurrent falls, and other medical conditions. Concerns included inadequate training and procedures for assessing head injuries and uncertainty about when to summon an ambulance, as well as the distance between the care service base and the deceased’s home.

    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 written guidance on when to summon an ambulance

    Wider context from the report

    “2. She stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases. There was nothing in writing advising as to when it is appropriate and/or necessary to summon an ambulance. ”

    Source location

    Kathleen Eaton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    Yusuf ABDISMAD · 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

    Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance

    Wider context from the report

    “During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”

    Source location

    Yusuf ABDISMAD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Exeter and Greater Devon

    AI-generated summary

    Hayden Meirion NORTON · 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

    Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.

    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

    Unavailability of an emergency code protocol for calling an ambulance

    Wider context from the report

    “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013, (1) there was no record that his blood pressure was monitored; or (2) that he had been informed of a screening test for aortic aneurysm. He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor. (3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol. There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come. ”

    Source location

    Hayden Meirion NORTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.

    Verbatim wording from the response

    “3.3. The third of the concerns relates to the HMP Dartmoor service, at the time of this report it is not clear whether the prison have been asked to respond separately or whether the Trust is expected to do so on their behalf. The Trust is awaiting a response from HM Coroner’s office to determine this. For the purposes of this report the third recommendation has been left for HMP Dartmoor Governing Governor Bridie Oaks-Richards to respond to as this is a prison responsibility.”

    Source location

    2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
    Page 2 · response
    Published 13 April 2015

    Open published response

  10. County Durham and Darlington

    AI-generated summary

    Sharon Louise Suki Butcher · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in summoning ambulances after emergency medical codes are broadcast

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026