6 Jan 2026 Adam Ali Hussain · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Midlands Ambulance Service NHS Trust NEMS NHS England NHS Nottingham and Nottinghamshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
NEMS
End manually pushed ambulance calls and use Directory of Services or automated ITK referrals meeting defined criteria.
View source
NEMS
Share recurring themes and concerning cases with EMAS, request review outcomes and learning, and participate in joint After Action Reviews.
View source
NEMS
Participate in a system After Action Review with the ICB, EMAS and DHU covering information transfer, deterioration recognition and role boundaries.
View source
NEMS
Deliver specialist teaching on appendicitis, evolving intra-abdominal sepsis, differential diagnosis and escalation for uncertainty.
View source
NEMS
Provide enhanced sepsis training and structured competency assessments for UCCH clinicians.
View source
NEMS
Use structured reflective practice and digital sepsis-screening prompts within Adastra to support clinical assessment.
View source
NHS Nottingham and Nottinghamshire Integrated Care Board
Review transferred call codes with comparable East Midlands services to assess whether wider removal is appropriate.
View source
NHS Nottingham and Nottinghamshire Integrated Care Board
Review and redefine the UCCH service specification to incorporate learning from the report.
View source
NHS Nottingham and Nottinghamshire Integrated Care Board
Develop joined-up analytics to understand patient journeys and outcomes across the pathway from March 2026.
View source
East Midlands Ambulance Service NHS Trust
Develop a technological solution with partner organisations to transfer complete patient information across urgent-care services.
View source
East Midlands Ambulance Service NHS Trust
Require clinicians to review available information and make all Category 3 transfers through a clinical-only process, ending manual pushes to NEMS.
View source See 8 more actions
×
AI-generated summary
Adam Ali Hussain · 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
Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.
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 the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response
” Source location Adam Ali Hussain · Prevention of Future Deaths report
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 End manually pushed ambulance calls and use Directory of Services or automated ITK referrals meeting defined criteria.
Verbatim wording from the response “Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or automated ITK pathways. These pathways present lower risk because they are generated through NHS Pathways and meet defined criteria, and no further sepsis-related patient safety incidents have been identified since pathway changes in June 2025. Since 27th June 2025, NEMS implemented a pause on manually pushed calls while improvements were agreed with EMAS. Although manual pushes resumed on 21st July following assurance regarding CAD note quality and governance arrangement, NEMS confirms that it has not continued with manually pushed calls since 3rd December 2025.NEMS continues to proactively review cases transferred from EMAS and escalate concerns through joint governance structures, alongside close monitoring of monthly UCCH highlight reports to identify emerging themes” Source location Response from Nottingham Emergency Medical Service
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 Share recurring themes and concerning cases with EMAS, request review outcomes and learning, and participate in joint After Action Reviews.
Verbatim wording from the response “NEMS will continue to share recurring themes and individual cases of concern with EMAS through established governance processes to ensure that identified risks are reviewed and that learning is clearly documented. We have requested that EMAS report back on the outcomes of those reviews and share any learning relevant to NEMS, so that the process operates as a genuinely reciprocal and joint approach rather than a one-directional escalation pathway.” Source location Response from Nottingham Emergency Medical Service
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 Participate in a system After Action Review with the ICB, EMAS and DHU covering information transfer, deterioration recognition and role boundaries.
Verbatim wording from the response “On 21st January, alongside the Medical Director, I attended a formal system After Action Review alongside the ICB Quality Team, EMAS and DHU. This review considered both cases in detail, identified shared learning themes and examined the collaborative approaches required to strengthen inter-organisational working. Focus was given to information transfer, recognition of clinical deterioration across multiple contacts, and clarity of role boundaries within the urgent care pathway. This system-level discussion reinforced that the risks identified were not isolated to one organisation and require coordinated improvement across providers.” Source location Response from Nottingham Emergency Medical Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specialist teaching on appendicitis, evolving intra-abdominal sepsis, differential diagnosis and escalation for uncertainty.
Verbatim wording from the response “On 3rd February, the Medical Director hosted a dedicated clinical teaching session in collaboration with Mr Chauhan, the consultant general surgeon who provided evidence at inquest. This session focused on the presentation of appendicitis, the variability of clinical features, the evolution of intra-abdominal sepsis, and the importance of considering differential diagnoses when symptoms appear non-classical. The session was well attended by NEMS clinicians and formed part of our strengthened education programme. It provided valuable specialist insight and reinforced the importance of clinical curiosity, escalation when uncertainty persists, and recognition of evolving systemic illness.” Source location Response from Nottingham Emergency Medical Service
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 Provide enhanced sepsis training and structured competency assessments for UCCH clinicians.
Verbatim wording from the response “These initiatives build upon the strengthened educational processes already described in the Organisational Learning Statement including enhanced sepsis training, structured competency assessments for UCCH clinicians, repeated clinical audits with reflective feedback, digital prompts such as the sepsis screening tool within Adastra, and tighter allocation of appropriately trained staff to high-acuity services.” Source location Response from Nottingham Emergency Medical Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use structured reflective practice and digital sepsis-screening prompts within Adastra to support clinical assessment.
Verbatim wording from the response “These initiatives build upon the strengthened educational processes already described in the Organisational Learning Statement including enhanced sepsis training, structured competency assessments for UCCH clinicians, repeated clinical audits with reflective feedback, digital prompts such as the sepsis screening tool within Adastra, and tighter allocation of appropriately trained staff to high-acuity services.” Source location Response from Nottingham Emergency Medical Service
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 transferred call codes with comparable East Midlands services to assess whether wider removal is appropriate.
Verbatim wording from the response “We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and redefine the UCCH service specification to incorporate learning from the report.
Verbatim wording from the response “As the commissioner of the UCCH we have also reviewed and redefined the existing service specification that is included in the contract we have with NEMS, ensuring that all learning has been included.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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 Develop joined-up analytics to understand patient journeys and outcomes across the pathway from March 2026.
Verbatim wording from the response “Our analytics team have recently developed the ability to join up multiple data sets that will from March 2026 allow us to understand the patient journey and outcomes across this entire pathway. This will support us to review and refine the journey for our patients, enhancing our ability to evaluate and adjust accordingly the service offer.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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 Develop a technological solution with partner organisations to transfer complete patient information across urgent-care services.
Verbatim wording from the response “required. To address this, EMAS has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision-making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Require clinicians to review available information and make all Category 3 transfers through a clinical-only process, ending manual pushes to NEMS.
Verbatim wording from the response “Historically, non-clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, EMAS implemented a significant change to operational practice:” Source location Response from East Midlands Ambulance Service NHS Trust
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 Concerns other than concern three are better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board.
Verbatim wording from the response “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.” Source location Response from NHS England
Open published response
5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Midlands Ambulance Service NHS Trust NEMS Community Benefit Services NHS England NHS Nottingham and Nottinghamshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
NHS Nottingham and Nottinghamshire Integrated Care Board
Review and redefine the UCCH service specification in the NEMS contract to incorporate learning from the report.
View source
NHS Nottingham and Nottinghamshire Integrated Care Board
Develop joined-up analytics capability to assess patient journeys and outcomes across the entire pathway.
View source
NEMS Community Benefit Services
Strengthen governance, clinical oversight and operational boundaries for urgent care pathway referrals.
View source
NEMS Community Benefit Services
Review transferred EMAS cases, monitor monthly UCCH themes, escalate risks and participate in joint governance and After Action Reviews.
View source
NEMS Community Benefit Services
Host specialist clinical teaching on appendicitis, evolving sepsis, differential diagnosis and escalation.
View source
NEMS Community Benefit Services
Maintain enhanced sepsis training, structured UCCH competency assessments, repeated clinical audits and reflective feedback.
View source
East Midlands Ambulance Service NHS Trust
Develop a technological solution with partner organisations to transfer complete patient information across urgent care services.
View source
East Midlands Ambulance Service NHS Trust
Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
View source See 5 more actions
×
AI-generated summary
Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 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 Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition is reached is for a Category 3 ambulance response
” Source location Jake Kieran Hartwright · Prevention of Future Deaths report
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 redefine the UCCH service specification in the NEMS contract to incorporate learning from the report.
Verbatim wording from the response “As the commissioner of the UCCH we have also reviewed and redefined the existing service specification that is included in the contract we have with NEMS, ensuring that all learning has been included.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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 Develop joined-up analytics capability to assess patient journeys and outcomes across the entire pathway.
Verbatim wording from the response “Our analytics team have recently developed the ability to join up multiple data sets that will from March 2026 allow us to understand the patient journey and outcomes across this entire pathway. This will support us to review and refine the journey for our patients, enhancing our ability to evaluate and adjust accordingly the service offer.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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 Strengthen governance, clinical oversight and operational boundaries for urgent care pathway referrals.
Verbatim wording from the response “As the evidence unfolded during the inquest, it became clear that the manual push model had the unintended consequence of positioning NEMS in a role more akin to an Emergency Operations Centre (EOC), rather than functioning as an urgent care provider operating within a clearly defined admission avoidance model. This was neither aligned with national GIRFT (Get it Right First Time) guidance nor consistent with the intended purpose of an Urgent Care Coordination Hub. GIRFT describes UCCHs as a single point of access supporting admission avoidance, coordinating community-based responses and enabling ambulance crews to access alternatives to conveyance. Since this time, we have strengthened our governance arrangements to ensure clear operational boundaries, robust clinical oversight, and full alignment with urgent primary care guidelines, thereby preventing a recurrence of this situation.” Source location Response from Nottingham Emergency Medical Service
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 transferred EMAS cases, monitor monthly UCCH themes, escalate risks and participate in joint governance and After Action Reviews.
Verbatim wording from the response “Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or automated ITK pathways. These pathways present lower risk because they are generated through NHS Pathways and meet defined criteria, and no further sepsis-related patient safety incidents have been identified since pathway changes in June 2025. Since 27th June 2025, NEMS implemented a pause on manually pushed calls while improvements were agreed with EMAS. Although manual pushes resumed on 21st July following assurance regarding CAD note quality and governance arrangement, NEMS confirms that it has not continued with manually pushed calls since 3rd December 2025. NEMS continues to proactively review cases transferred from EMAS and escalate concerns through joint governance structures, alongside close monitoring of monthly UCCH highlight reports to identify emerging themes” Source location Response from Nottingham Emergency Medical Service
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 Host specialist clinical teaching on appendicitis, evolving sepsis, differential diagnosis and escalation.
Verbatim wording from the response “On 3rd February, the Medical Director hosted a dedicated clinical teaching session in collaboration with Mr Chauhan, the consultant general surgeon who provided evidence at inquest. This session focused on the presentation of appendicitis, the variability of clinical features, the evolution of intra-abdominal sepsis, and the importance of considering differential diagnoses when symptoms appear non-classical. The session was well attended by NEMS clinicians and formed part of our strengthened education programme. It provided valuable specialist insight and reinforced the importance of clinical curiosity, escalation when uncertainty persists, and recognition of evolving systemic illness.” Source location Response from Nottingham Emergency Medical Service
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 Maintain enhanced sepsis training, structured UCCH competency assessments, repeated clinical audits and reflective feedback.
Verbatim wording from the response “These initiatives build upon the strengthened educational processes already described in the Organisational Learning Statement including enhanced sepsis training, structured competency assessments for UCCH clinicians, repeated clinical audits with reflective feedback, digital process such as the sepsis screening tool within Adastra, and tighter allocation of appropriately trained staff to high-acuity services.” Source location Response from Nottingham Emergency Medical Service
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 Develop a technological solution with partner organisations to transfer complete patient information across urgent care services.
Verbatim wording from the response “The Trust recognises that, while the urgent care pathway performs well for most patients, those presenting with serious but not immediately life-threatening systemic illness may not be supported as effectively as required. To address this, the Trust has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision-making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
Verbatim wording from the response “In December 2025, the Trust upgraded its CAD system to ensure that all information captured during the initial 999 call is automatically transmitted to subsequent receiving systems. This enhancement has been fully tested with the Trust and NEMS and now supports the transfer of more comprehensive clinical information at the point of referral.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Concerns about the urgent care pathway, CAD information, Category 3 call handling and transfer criteria should be addressed by EMAS, NEMS and the ICB.
Verbatim wording from the response “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.” Source location Response from NHS England
Open published response
6 Nov 2024 Simon Boyd · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to adhere to national ambulance response-time targets View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Simon Boyd · 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
Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.
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 adhere to national ambulance response-time targets
Wider context from the report “1. The court heard evidence to the effect that, notwithstanding the national target for Category 3 99% calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes. This is a factor which contributed to decision-making in this case.
I am concerned that national targets for ambulance response times continue not to be adhered to .
” Source location Simon Boyd · Prevention of Future Deaths report
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 a national directive requiring clinical validation of Category 3 and Category 4 ambulance responses in NHS 111 and 999 services.
Verbatim wording from the response “In order to support ambulance providers to manage their available resources, NHS England has issued a national directive, requiring providers to undertake clinical validation of Category 3 and Category 4 ambulance responses within both NHS 111 and 999 services. This involves validation of the disposition by a clinician (arranged locally), which can result in a different disposition being subsequently reached. The information captured in NHS Pathways may allow a clinician to re-categorise the call without direct contact with the patient. The Ambulance Trust’s Computer Aided Dispatch (CAD) system, rather than NHS Pathways, is used to manage the validation process. It is a requirement that the CAD must be able to provide appropriate exit scripts for Category 3 / Category 4 codes or dispositions. The wording of the exit scripts is for local determination.” Source location Response from NHS England
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 Support the NHS, including ambulance services, to achieve safe operational response-time standards.
Verbatim wording from the response “This Government recognises that in recent years, ambulance response time performance has been below the high standards that patients should expect. That is why this Government has committed to supporting the National Health Service to improve performance, including ambulance services achieving the safe operational response times standards set out in the NHS Constitution.” Source location Response from DHSC
Open published response
3 May 2024 Michael Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to account for actual category 3 ambulance response times when accepting call categorisation View source Delays in category 3 ambulance responses View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Publish the Delivery Plan for recovering urgent and emergency care services, including actions to improve ambulance response times and capacity.
View source
NHS England
Maintain ambulance capacity increases achieved during 2023/24 to support improved response times.
View source
NHS England
Continue developing alternative referral pathways, including urgent community response, to provide timely and appropriate care.
View source
NHS Greater Manchester Integrated Care Board
Monitor achievement of all Ambulance Response Programme standards through the North West Ambulance Improvement Plan and regional urgent-care governance arrangements.
View source See 1 more action
×
AI-generated summary
Michael Clarke · 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
Michael Clarke, who had multiple underlying health conditions including end stage renal failure, developed suspected urosepsis after a cystoscopy and died in hospital on 30 July 2023. The report raised concerns about delays in category 3 ambulance responses, the categorisation of a call where sepsis was suspected, and the absence of specific sepsis trigger questions on the ambulance pathway.
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 account for actual category 3 ambulance response times when accepting call categorisation
Wider context from the report “2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour .
” Source location Michael Clarke · Prevention of Future Deaths report
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 Delays in category 3 ambulance responses
Wider context from the report “1. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour . The inquest was told that this was not unusual and was still an ongoing issue . The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays .
” Source location Michael Clarke · Prevention of Future Deaths report
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 Publish the Delivery Plan for recovering urgent and emergency care services, including actions to improve ambulance response times and capacity.
Verbatim wording from the response “Your first concern is centred on the significant demand and waiting times for a Category 3 ambulance which was more than four hours rather than the one-hour target. NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023.” Source location Response from NHS England and NHS GMIC
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 Maintain ambulance capacity increases achieved during 2023/24 to support improved response times.
Verbatim wording from the response “The plan outlined key actions to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms), alongside broader system actions to improving flow through hospitals and reducing handover delays, speeding up discharges from hospitals and expanding new services in the community, all of which should help ambulance crews to get back on the road to the next waiting patient more rapidly.” Source location Response from NHS England and NHS GMIC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing alternative referral pathways, including urgent community response, to provide timely and appropriate care.
Verbatim wording from the response “Whilst ambulance response times have not returned to pre-pandemic levels, there were improvements in ambulance response times nationally during 2023/24. The 2023/24 year-end Category 3 Mean time to respond was 2 hours 4 minutes 14 seconds which is 31 minutes 4 seconds quicker than 2022/23 and the 2023/24 year-end Category 2 Mean was 36 minutes 23 seconds which is 13 minutes 37 seconds quicker than 2022/23. For 2024/25, the Delivery Plan continues to focus on the improvement of ambulance response times, with ambulance services expected to maintain the increases in capacity achieved throughout 2023/24, alongside the continued development of alternative referral pathways (e.g. urgent community response) to ensure that patients receive timely and high-quality care.” Source location Response from NHS England and NHS GMIC
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 Monitor achievement of all Ambulance Response Programme standards through the North West Ambulance Improvement Plan and regional urgent-care governance arrangements.
Verbatim wording from the response “We acknowledge this is still not achieving the national standards which is why for 2024/25 achieving all ARP standards, not just the NHS England UEC recovery plan of category 2 mean, is part of the North West Ambulance Improvement Plan being monitored by the North West Ambulance and 111 commissioning team and UEC ICB leads at the Strategic Partnership and Transformation Board which includes NHS England UEC Regional representation.” Source location Response from NHS England and NHS GMIC
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 Category 3 ambulance categorisation was audited and considered safe and appropriate based on the patient’s presentation.
Verbatim wording from the response “You also raised a concern that the initial call to North West Ambulance Service (NWAS) was made by an out of hours Nurse who requested an ambulance within one hour as this is consistent with Category 3 response call-outs. It was not considered then that on that evening a Category 3 call was not going to result in an ambulance attending within one hour.” Source location Response from NHS England and NHS GMIC
Open published response
9 May 2023 Sandra Dianne Finch · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2
Lack of a prioritisation system for category 3 ambulance call assessments View source Lack of time limits for category 3 ambulance call assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Sandra Dianne Finch · 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
Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 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 Lack of a prioritisation system for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system , will lead to further deaths resulting from delays.
” Source location Sandra Dianne Finch · Prevention of Future Deaths report
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 Lack of time limits for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place , and no prioritisation system, will lead to further deaths resulting from delays.
” Source location Sandra Dianne Finch · Prevention of Future Deaths report
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 Have senior clinical navigators risk-assess patients awaiting clinical assessment, arrange ambulance dispatch for unsuitable patients, and upgrade incidents when indicated.
Verbatim wording from the response “All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily.” Source location Response from West Midlands Ambulance Service
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 Prioritise category 3 and 4 clinical-assessment callbacks in incident-category time order, targeting contact within 60 minutes.
Verbatim wording from the response “The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.” Source location Response from West Midlands Ambulance Service
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 Highlight patients waiting over 120 minutes, and every subsequent 120 minutes, for further clinical-navigator risk assessment.
Verbatim wording from the response “The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.” Source location Response from West Midlands Ambulance Service
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 clinical validation, prioritisation, risk assessment and escalation arrangements are considered sufficient to manage category 3 and 4 delays safely.
Verbatim wording from the response “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, led to the clinical validation team becoming a substantiated process within the Trust.” Source location Response from West Midlands Ambulance Service
Open published response
19 Nov 2019 Helen BARKER · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Helen BARKER · 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
Helen BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded
Wider context from the report “1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:-
Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust.
Has this recommendation now been implemented particularly where attempted suicides have been reported.
Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded?
” Source location Helen BARKER · Prevention of Future Deaths report
Open source report
7 Oct 2019 Alf REWIN · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1
Failure of overdose call categorisation to ensure timely ambulance response View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Deploy Release 18, including the Dx0124 disposition code, to identify higher-risk suicide cases for early clinical review.
View source
NHS England
Develop a disposition code for symptomatic accidental-overdose patients, subject to National Clinical Governance Group review, to enable urgent clinical risk assessment.
View source
×
AI-generated summary
Alf REWIN · 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
Alf Rewin died at Wexham Park Hospital on 22 November 2018 after taking an overdose of Quetiapine, Methylphenidate and Duloxetine and becoming unresponsive before arrival. The principal concern was that overdose cases could receive a Category 3 ambulance response with a target of up to 120 minutes, despite the risk of unconsciousness, cardiac arrest or other potentially fatal events requiring earlier attendance.
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 overdose call categorisation to ensure timely ambulance response
Wider context from the report “The National Ambulance Call Categories prescribed by NHS Pathways to ambulance services, including South Central Ambulance Service, who were the attending service in relation to Alf Rewin's death, indicate that an individual contacting emergency services himself or herself, having taken an overdose may be triaged through the national call handling pathway to a Category 3 Urgent Call. This category currently prescribes a target ambulance within 120 minutes.
There is a concern that in cases of overdose, the patient is at risk of becoming unconscious or having a cardiac arrest or other potentially fatal event and will be unable to contact emergency services or be contacted by them subsequently, such that his or her call should at that stage then be regarded as Category 1 (with a 7 minute response time) or Category 2 (with an 18 minute response time).
In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute response in overdose cases to provide a specific triage which could lead to a Category 2 18-minute response (although the 18-minute response was not, in fact, implemented at the outset in Alf Rewin’s case and he was initially allocated the national Category 3 response).
It is understood that the national categorisation of overdose cases is under review.
Whilst the Category 3 120-minute target may be the standard, subject to local variation, in relation to overdose cases where the patient is conscious, the risk of deaths arising during this period remains where the circumstances of the overdose might enable some counteractive treatment to be given, or successful resuscitation measures to be carried out, if there were to be earlier attendance and / or earlier hospitalisation.
” Source location Alf REWIN · Prevention of Future Deaths report
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 Deploy Release 18, including the Dx0124 disposition code, to identify higher-risk suicide cases for early clinical review.
Verbatim wording from the response “Release 18 changes:” Source location 2019-0469-Response-by-NHS-Digital
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 Develop a disposition code for symptomatic accidental-overdose patients, subject to National Clinical Governance Group review, to enable urgent clinical risk assessment.
Verbatim wording from the response “NHS Pathways has also recognised that those patients who have overdosed without suicidal intent and have symptoms (and so receive a Dx012 disposition and Category 3 ambulance) would benefit from having the same visibility within the Category 3 cohort as those with suicidal intent, so they can also be easily identified by clinicians working within ambulance control rooms for urgent remote clinical assessment of the risk to life. Further work by the NHS Pathways team is commencing in this area and, subject to review by the National Clinical Governance Group, a new disposition code will be introduced (similar to Dx0124) to enable this to occur. The Ambulance Response Programme will be made aware of this proposed change.” Source location 2019-0469-Response-by-NHS-Digital
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 Ambulance response standards and category mappings are set by NHS England, not by NHS Pathways.
Verbatim wording from the response “National ambulance call categories are not prescribed by NHS Pathways to ambulance services.” Source location 2019-0469-Response-by-NHS-Digital
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 NHS Pathways cannot automatically identify higher-risk overdoses from drugs taken because closed questions cannot safely capture the relevant variables.
Verbatim wording from the response “A) Assessment of drugs taken” Source location 2019-0469-Response-by-NHS-Digital
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.