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

    Max Carlton-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

    Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

    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 ambulance services after a medical collapse

    Wider context from the report

    “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did. ”

    Source location

    Max Carlton-Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    RHYS TUDOR 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

    On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

    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 staff know to call an ambulance directly when required

    Wider context from the report

    “9. Some members of staff were clearly under the impression that they should not call an ambulance but should contact the nurse on site who would then do so. This could lead to unacceptable delays in the attendance of potentially life-saving emergency services. Has this misapprehension been addressed? ”

    Source location

    RHYS TUDOR WILLIAMS · 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

    Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.

    Verbatim wording from the response

    “A communication has been sent to staff (with instruction to be discussed and signed for at handover) that the emergency services must be called by the person discovering the incident if the situation warrants it, and to clarify that there is no need to delay this process by finding the nurse. To ensure that this communication is embedded into the organisation it has been added to the General Managers’ training which is in turn delivered to all team members as they join Sunrise.”

    Source location

    2014-0558-Response-by-Sunrise-Senior-Living
    Page 4 · response
    Published 15 December 2014

    Open published response

  3. Portsmouth and South East Hampshire

    AI-generated summary

    GARRY GILBEY · 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

    Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a set policy for when to call an ambulance

    Wider context from the report

    “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night. ”

    Source location

    GARRY GILBEY · 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

    Issue national guidance requiring ambulance calls and immediate ambulance access protocols for prisoners in life-threatening emergencies.

    Verbatim wording from the response

    “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 1 · response
    Published 10 December 2014

    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 emergency-response instructions specifying medical emergency codes, required information, local protocols and staff responsibilities.

    Verbatim wording from the response

    “Calling ambulances Since Mr Gilbey’s death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and understand the instruction and their responsibilities during medical emergencies. I have attached a copy of the PSI for your information.”

    Source location

    2014-0533-Response-by-NOMS
    Page 1 · response
    Published 10 December 2014

    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

    Existing emergency-access guidance applies during emergencies outside normal healthcare-centre hours, so 24-hour medical cover is not necessarily required.

    Verbatim wording from the response

    “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 1 · response
    Published 10 December 2014

    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 prison Governor or Director is responsible for ensuring each prison has an ambulance-access protocol.

    Verbatim wording from the response

    “• It is the responsibility of the Governing Governor/Director to ensure that a protocol exists at each prison (regardless of security status) to facilitate immediate access for the ambulance service to both the prison and the individual prisoner when required.”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 2 · response
    Published 10 December 2014

    Open published response

  4. Inner North London

    AI-generated summary

    William DAVIES · 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

    William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to request an ambulance promptly after a level one call

    Wider context from the report

    “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. 1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one. However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court. 2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. ”

    Source location

    William DAVIES · 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

    Confusion over requesting an ambulance after a level one call

    Wider context from the report

    “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

    Source location

    William DAVIES · 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

    Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    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 emergency care arrangements, including staff training and standardisation of emergency bags.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    Open published response

  5. West Yorkshire Eastern

    AI-generated summary

    William Thomas Anderson · 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

    William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

    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 emergency medical services

    Wider context from the report

    “(5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons outside medical assistance sooner would not have affected the outcome in this instance, it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate’s chances of survival. Consequently, emergency services should be summoned at the very first available opportunity, and all Prison staff should be instructed as to the importance of so doing. ”

    Source location

    William Thomas Anderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. County Durham and Darlington

    AI-generated summary

    Kirk Duboise · 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

    Kirk Duboise arrived at HMP Durham with documents highlighting self-harm risks, but the documents were not seen and an ACCT was not opened. He was found dead in his cell approximately eight hours after arrival; concerns included the failure to identify the relevant forms and a delay in summoning an ambulance.

    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

    Delay in summoning an ambulance

    Wider context from the report

    “(1) The delay in summoning an ambulance. ”

    Source location

    Kirk Duboise · 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

    Introduce and disseminate a colour-coded ambulance-summoning system to all staff through notices and briefings.

    Verbatim wording from the response

    “Prison Service Instruction (PSI 03/2013/Medical Emergency Response Codes) came into effect after Mr Duboisle’s death. As a result a colour code system for the summoning of an ambulance has been introduced. This has been disseminated to all staff. A Governor’s notice to staff entitled ‘Summoning medical assistance Hotel 1/Ambulance’, was issued and is dated 22nd April 2013. This was also brought to the attention of staff by the head of healthcare at a full staff briefing, the minutes of which are sent to all staff.”

    Source location

    2013-0329-Response-by-Care-UK
    Page 2 · response
    Published 22 February 2014

    Open published response

  7. West Yorkshire (East)

    AI-generated summary

    Annie Rose GIBSON · 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

    Annie Rose Gibson, an 84-year-old woman living alone, was found unresponsive at home after a fall the previous day and was pronounced dead on 13 October 2012. The post-mortem cause of death was recorded as hypothermia, immobility, and fractured pelvis with haemorrhage. The principal concern was that emergency medical assistance was not obtained despite the fall and injury, and that hospital treatment might have prevented the development of hypothermia and the 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 of training protocols and Care Plans to ensure emergency-service calls and ambulance attendance despite client wishes

    Wider context from the report

    “My recommendations are that you should address situations such as this in your training protocols and Care Plans to ensure that your carers would always, notwithstanding the wishes of your client, call the Emergency Services and ensure ambulance attendance. I also recommend that the wishes of the client would have to be overridden in such a situation, in particular when relatives cannot be contacted. ”

    Source location

    Annie Rose GIBSON · 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