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 North London

    AI-generated summary

    Haaris Amin BHATTI · 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

    Haaris Amin BHATTI took drugs before entering Fold Nightclub and took more drugs while inside. He became seriously unwell, but nightclub staff delayed calling an ambulance; the report states that this delay decreased his chance of survival and reflected the club’s training and culture.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to call an ambulance promptly for a medical emergency

    Wider context from the report

    “At approximately 4.45am, Haaris was noted by nightclub staff to be unwell and was taken to the welfare room in a wheelchair. He was very hot, had an extremely fast heart rate and extremely high blood pressure, and appeared to the club first aider to be psychotic. He was monitored and he later explained that he had taken ████████. However, there was a failure by club staff to call an ambulance until 5.57am. Staff agreed with me at inquest that they should have called an ambulance as soon as they got Haaris into the welfare room and saw his condition. The delay in seeking definitive medical care decreased Harris’s chance of survival. The delay did not seem to me to be simply about any individual member of staff, but rather it reflected the club’s training and culture as a whole. Staff were concerned for Haaris, but this concern did not translate into effective management of his medical emergency. ”

    Source location

    Haaris Amin BHATTI · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and strengthen welfare escalation procedures for prompt emergency-service contact when guests present serious symptoms.

    Verbatim wording from the response

    “We recognise the concern identified during the inquest that emergency medical services should have been contacted earlier once Haaris was brought to the welfare area. Following the events of July 2025 we reviewed our escalation procedures to ensure that emergency medical services are contacted promptly where a guest presents with serious symptoms.”

    Source location

    Response from FOLD nightclub
    Page 1 · response
    Published 29 January 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require immediate ambulance calls when a guest’s vital signs and temperature are high, regardless of hallucinations or antidepressant history.

    Verbatim wording from the response

    “This prompted us to adapt our welfare protocols to immediately call an ambulance if the combination of a guests’ vitals and temperature are high, irrespective of the hallucinations presented or previous history with anti-depressants. This approach is intended to remove uncertainty and ensure that guests receive prompt access to professional medical care where necessary.”

    Source location

    Response from FOLD nightclub
    Page 2 · response
    Published 29 January 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Contract and deploy Frontline Medical Response medical staff and life-support equipment at all nighttime events to support welfare assessment and escalation.

    Verbatim wording from the response

    “We have contracted the services of Frontline Medical Response LTD, to be present for all nighttime events moving forward. In addition to their medical staff being present on all events, with additional life-supporting equipment, their medical staff will work alongside our welfare team and assist with medical assessment and escalation where required.”

    Source location

    Response from FOLD nightclub
    Page 2 · response
    Published 29 January 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Ian George Stanton SIMPSON · 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

    Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.

    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 emergency ambulance for very unwell residents

    Wider context from the report

    “1. Mr Simpson was found unresponsive by care home staff at about 09:30 on 16 December 2024, and an emergency ambulance was not called until 10:19. On the evidence in this particular case, that delay did not more than minimally contribute to death; however, it would or should have been obvious to staff that the resident was very unwell and required an ambulance as soon as possible. This raises the concern that such a delay, if repeated, places others at serious risk. My concern was compounded by the evidence from the manager (which I did not wholly accept) that it would be reasonable to take this period of time for a nurse to be alerted, assess the resident, and decide whether an ambulance was required. ”

    Source location

    Ian George Stanton SIMPSON · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Present learning from the matter to home managers, including escalation expectations and immediate 999 calls for newly unresponsive residents.

    Verbatim wording from the response

    “• I presented learning from this matter to all our home managers during our ‘Leading the way’ internal communication webinar on 19th May 2025. This session covered responsibility to escalate any concerns in relation to residents’ health and welfare and utilise the guidance provided in our Deteriorating Resident’s Policy and that 999 must be immediately called for an unresponsive resident where this represents a new presentation.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 3 · response
    Published 21 May 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete themed supervisions covering RESTORE2 clinical judgement and managing resident deterioration.

    Verbatim wording from the response

    “• Themed supervisions have been completed with the support of Divisional Clinical Lead Nurse, the Clinical Development Nurse and both the Regional Director and General Manager of the Home. These themed supervisions cover two main areas:”

    Source location

    Response from Barchester Healthcare Ltd
    Page 3 · response
    Published 21 May 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide staff with Clinical Shots guidance for assessing residents and responding to deterioration.

    Verbatim wording from the response

    “• Staff in the Home have also been provided with Barchester ‘Clinical Shots’ guidance, to inform their assessment of residents and the steps to be taken in response.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 4 · response
    Published 21 May 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The reported 09:30 incident time is unsupported; staff identified no concerns about the resident’s health or wellbeing then.

    Verbatim wording from the response

    “• it is not clear where the time of 09:30am as the time of the incident originates. Whilst this is recorded in the Accident and Incident Form, no member of staff suggested that there were any concerns at this time in respect of Mr Simpson’s health and wellbeing.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 1 · response
    Published 21 May 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Staff did not consider a 49-minute escalation period appropriate for an unresponsive resident and recalled no significant delay in this case.

    Verbatim wording from the response

    “• Despite the evidence given, no other member of the Nursing team considered that 49 minutes is an appropriate length of time to escalate concerns to 999 if a resident is found unresponsive and staff did not recall there being any significant delay in doing so in Mr Simpson’s case.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 2 · response
    Published 21 May 2025

    Open published response

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · 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

    Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his 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

    Failure to call an ambulance promptly following a concern for welfare call

    Wider context from the report

    “2) Information sharing between SWAST and D&CP. A number of issues were revealed during the course of the evidence. a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours. b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate. c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.) d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached. e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options. f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial? ”

    Source location

    Lachlan Charles Campbell · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.

    Verbatim wording from the response

    “As a part of RCRP, if our police officers come across or attend an incident in respect of which they deem that there is a requirement for additional medical support, they are trained to telephone 999 from the scene. This is to seek to ensure that the 999 operator can liaise directly with the person who has the patient with them and can offer appropriate treatment, as well as allocating a resource to attend.”

    Source location

    Response from Devon and Cornwall Police
    Page 2 · response
    Published 4 March 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.

    Verbatim wording from the response

    “If our officers call for an ambulance through the police control room, they are asked if there is a reason that they cannot do this themselves (such as the need to commence CPR, or other environmental factors). Police control room and SWAST personnel are trained to record all relevant information when contacting or otherwise liaising with SWAST.”

    Source location

    Response from Devon and Cornwall Police
    Page 2 · response
    Published 4 March 2025

    Open published response

  4. Inner North London

    AI-generated summary

    Student A · 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

    Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and 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

    Delays in escalating and responding to an apparent emergency

    Wider context from the report

    “2. When attending Student A’s room at about 10:50 on 28 July 2024, the member of staff knocked repeatedly on the door and asked for Student A to come to the door. The staff member then used their staff pass to open the door, on account of getting no response. In their statement, the staff member sets out that they remained in the doorway and could see Student A’s legs (from the knees down) on the bed within the room. The statement continues, ‘I called out to the student and stated that it was reception and asked if they were okay. At this time I was scared so I closed the door and went to the stairwell.’ The staff member spoke to the ECC and explained the circumstances to them and the ECC advised the staff member to call an ambulance ‘and to also get someone from one of the other buildings that is run by the university.’ Following the call with the ECC, the staff member sent a text message to their ‘general manager’ explaining the situation and requesting that a receptionist from another building be sent to assist. The staff member’s statement then says, ‘At approximately 1134 I called my manager and whilst on the phone returned to the room and knocked on the door repeatedly. I shouted out and knocked twice. The student did not answer the door.’ The staff member then returned to reception and telephoned for a colleague in another building to come and assist. Assistance from a colleague arrived at approximately 12 noon. Both members of staff then made their way to Student A’s room where, upon entering they found Student A unresponsive on his bed in the manner already described at section 4 of this report. As a result, the staff left the room, returned to reception and ‘called our managers and emergency services and we waited for their arrival.’ The concerns here are numerous: • It was obvious to staff that Student A was, at the very least, unresponsive / difficult to rouse at about 10:50, which on any view would be regarded as a serious / emergency situation. However, it appears that no positive or definitive action was taken to assist for over an hour. • The ECC advised the staff member to call an ambulance at about 10:50, yet this was not done until approximately 12 noon. • The staff member who first checked on Student A at 10:50, went no further than threshold (seeing no more than his legs) and therefore did little, if anything, to satisfy themselves about the true welfare status of Student A. • The staff members who attended Student A’s room at approximately 12 noon, did not attempt to render basic assistance or first aid to Student A. • In the particular circumstances of Student A’s case, he was highly likely to have been deceased for hours prior to his death being verified by paramedics at 12:27. However, that fact was not known to staff at the material time and, therefore, they would have been expected to act in accordance with any protocols or policy in place at that time. Given these matters, I am concerned that there may be a lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective. Nothing in the evidence available to me has suggested that the future risks posed by my concerns have been addressed. ”

    Source location

    Student A · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.

    Verbatim wording from the response

    “We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:”

    Source location

    Response from Unite Students
    Page 2 · response
    Published 28 January 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review training, policies and procedures so staff promptly contact emergency services alongside requesting assistance for room entry during safety concerns or emergencies.

    Verbatim wording from the response

    “We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:”

    Source location

    Response from Unite Students
    Page 2 · response
    Published 28 January 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.

    Verbatim wording from the response

    “More generally, we are reviewing all our procedures for dealing with calls made to the ECC to effectively triage calls received, and to ensure that appropriate questions are asked to understand the basis and potential seriousness of enquiries.”

    Source location

    Response from Unite Students
    Page 3 · response
    Published 28 January 2025

    Open published response

  5. Inner North London

    AI-generated summary

    Nimo OSMAN · 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

    Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in calling emergency ambulances

    Wider context from the report

    “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. ”

    Source location

    Nimo OSMAN · 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

    Complete refresher Intermediate Life Support training for the nurse involved.

    Verbatim wording from the response

    “5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summons help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.”

    Source location

    Response from East London Foundation Trust
    Page 3 · response
    Published 13 August 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.

    Verbatim wording from the response

    “6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.”

    Source location

    Response from East London Foundation Trust
    Page 3 · response
    Published 13 August 2024

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.

    Verbatim wording from the response

    “4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is”

    Source location

    Response from East London Foundation Trust
    Page 2 · response
    Published 13 August 2024

    Open published response

  6. Dorset

    AI-generated summary

    Frazer Charlie Williams · Prevention of Future Deaths report

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

    Report summary

    Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his 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

    Failure to make an immediate ambulance call when a code blue or red is raised

    Wider context from the report

    “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised. ”

    Source location

    Frazer Charlie Williams · Prevention of Future Deaths report
    Page 7 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Circulate and mandate Code Red/Blue NTS and follow PSI contingency responses.

    Verbatim wording from the response

    “Code red/blue NTS was recently circulated and labelled mandatory. All contingency responses (Annex A of the PSI) is followed and was on the last 2 deaths.”

    Source location

    Response from HMPPS / HMP Guys Marsh
    Page 4 · response
    Published 6 June 2024

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.

    Verbatim wording from the response

    “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 6 June 2024

    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

    Mandatory code red and blue procedures and PSI contingency arrangements are considered sufficient and are being followed.

    Verbatim wording from the response

    “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised.”

    Source location

    Response from HMPPS / HMP Guys Marsh
    Page 4 · response
    Published 6 June 2024

    Open published response

  7. Gloucestershire

    AI-generated summary

    Severine Alexia Kelly · 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

    Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.

    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

    Uncertainty about when medical professionals should call the ambulance service

    Wider context from the report

    “There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service. ”

    Source location

    Severine Alexia Kelly · 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

    Review the medical-emergency escalation process and reinforce it through resuscitation training.

    Verbatim wording from the response

    “We have reviewed the existing process regarding actions to be taken in the event of a medical emergency and believe that this remains fit for purpose, I have attached a copy of the Escalation Procedure Action Card for your information at Appendix 3. This forms part of the Care of the Deteriorating Patient Policy and will be reinforced at all resuscitation training courses. Local escalation procedures are also included as part of the on-site local induction for new starters, therefore, all staff on site should be familiar with the process. In addition, to ensure that staff have a greater awareness of how to respond to a serious choking episode, we have developed a choking simulation to complement the Resuscitation Action Card 5 – Adult Choking (revised in November 2022) which has been included as part of the Level 3 Resuscitation Training from 1 April 2024.”

    Source location

    Response from Gloucestershire Health and Care NHS Foundation Trust
    Page 3 · response
    Published 23 February 2024

    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 existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.

    Verbatim wording from the response

    “We have reviewed the existing process regarding actions to be taken in the event of a medical emergency and believe that this remains fit for purpose, I have attached a copy of the Escalation Procedure Action Card for your information at Appendix 3. This forms part of the Care of the Deteriorating Patient Policy and will be reinforced at all resuscitation training courses. Local escalation procedures are also included as part of the on-site local induction for new starters, therefore, all staff on site should be familiar with the process. In addition, to ensure that staff have a greater awareness of how to respond to a serious choking episode, we have developed a choking simulation to complement the Resuscitation Action Card 5 – Adult Choking (revised in November 2022) which has been included as part of the Level 3 Resuscitation Training from 1 April 2024.”

    Source location

    Response from Gloucestershire Health and Care NHS Foundation Trust
    Page 3 · response
    Published 23 February 2024

    Open published response

  8. Nottinghamshire

    AI-generated summary

    Tammy Mary Louise WATKINS · 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

    Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

    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

    Unclear responsibility for calling a medical emergency

    Wider context from the report

    “4. Emergency Medical Calls There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service. It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient. Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed. This appears to be a training issue. ”

    Source location

    Tammy Mary Louise WATKINS · 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

    Review and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.

    Verbatim wording from the response

    “4. Emergency Medical Calls The process for emergency medical calls within Rampton Hospital has been reviewed and the process has been reinforced back to all staff that where immediate concerns are present regarding the physical health of a patient, it is expected that they will call for an ambulance. This is reviewed in line with the increased senior leadership and local learning.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

  9. Sefton, St Helens and Knowsley

    AI-generated summary

    Wayne MILNE · 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

    Wayne Milne attended hospital with chest pain on 28 February 2022 but was discharged without required chest-pain assessments and senior review. On 2 March 2022, after reporting further symptoms to his GP practice, he was advised to attend the emergency department, but the nurse did not call 999, escalate to a doctor, or check whether he had obtained urgent care; Wayne was later found deceased at home from haemopericardium due to a dissecting aortic aneurysm. The report identifies concerns about inconsistent procedures for summoning emergency assistance, escalation and follow-up, and awareness of dissecting aortic aneurysm within the practice.

    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 summon emergency medical assistance when required

    Wider context from the report

    “2. The nurse at the practice told the Inquest, the procedure for practice staff calling 999 (not leaving it to the patient) in the event of a patient with chest pain and other life threatening conditions applied only to reception staff and not to nursing staff. This led to inconsistency and in this case an avoidable delay in summoning urgent medical assistance and needs reviewing/all staff working in/working on behalf of the practice need to be aware of the procedure to be followed, consideration must be given as to whether it is appropriate to have different standards for qualified nursing and administrative/non qualified nursing staff. The awareness of Dissecting Aortic Aneurysm and the rapidity at which the condition can become catastrophic/fatal also needs raising within the practice. The nurse within the practice who spoke with Wayne on the date of his death on behalf of the practice , did not escalate to a doctor, did not call 999, she did not inform the NOK of her concerns, she did not call back to see if Wayne had called for an ambulance/attended hospital and she did not alert the hospital of her suspicions i.e. differential diagnoses including; PE, cardiac related problem or aortic aneurysm. The GP to whom this regulation 28 (Prevention of Future death) report is addressed informed the court (in a witness statement) no action had been taken within the practice since these events. ”

    Source location

    Wayne MILNE · 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 apply the emergency-calling procedure consistently across practice staff

    Wider context from the report

    “2. The nurse at the practice told the Inquest, the procedure for practice staff calling 999 (not leaving it to the patient) in the event of a patient with chest pain and other life threatening conditions applied only to reception staff and not to nursing staff. This led to inconsistency and in this case an avoidable delay in summoning urgent medical assistance and needs reviewing/all staff working in/working on behalf of the practice need to be aware of the procedure to be followed, consideration must be given as to whether it is appropriate to have different standards for qualified nursing and administrative/non qualified nursing staff. The awareness of Dissecting Aortic Aneurysm and the rapidity at which the condition can become catastrophic/fatal also needs raising within the practice. The nurse within the practice who spoke with Wayne on the date of his death on behalf of the practice , did not escalate to a doctor, did not call 999, she did not inform the NOK of her concerns, she did not call back to see if Wayne had called for an ambulance/attended hospital and she did not alert the hospital of her suspicions i.e. differential diagnoses including; PE, cardiac related problem or aortic aneurysm. The GP to whom this regulation 28 (Prevention of Future death) report is addressed informed the court (in a witness statement) no action had been taken within the practice since these events. ”

    Source location

    Wayne MILNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Nottinghamshire

    AI-generated summary

    Andrew Vizard · 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

    Andrew Vizard, aged 58, died from a pulmonary embolism on 14 July 2022 after suffering cardiac arrests while detained in hospital under section 2 of the Mental Health Act 1983. The report identified delays in obtaining monitoring equipment, a ward doctor attending, and calling an ambulance when concerns arose about his breathing. It also raised concern that existing staff training and emergency-response systems may not ensure an immediate and effective response in similar life-threatening situations.

    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 for patients with concerns for their breathing

    Wider context from the report

    “Despite there being concerns for an unresponsive patient’s breathing, it took: a) At least 6 minutes to obtain and utilise physical monitoring equipment. b) Nearly ten minutes for a ward doctor to attend the patient. c) Over 10 minutes for an ambulance to be called. Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing. Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur. ”

    Source location

    Andrew Vizard · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026