Recurring concern

Failure to locate patients requiring assessment

First to latest report 29 Jul 2014 — 8 Aug 2021

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures of dedicated processes to establish or verify the whereabouts or living location of patients who require assessment or urgent care, including use of available contact routes, collateral information, address information and ambulance or emergency-dispatch location procedures.

What is not included
  • Excludes general missing-person responses where no patient-assessment or healthcare-safety context is identified.
  • Excludes routine appointment tracking, referral tracking or case monitoring when the material concern is not locating a patient whose whereabouts are unknown.
  • Excludes generic communication, training or documentation deficiencies unless they directly impair the process of locating a patient requiring assessment.
  • Excludes failures to assess, treat or follow up a patient after their location has been established.

Reports and published responses 3 reports

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

  1. Mid Kent and Medway

    AI-generated summary

    STEVE MARTIN BRIAN COOKE · 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

    Steve Martin Brian Cooke had COVID-19 pneumonia following a COVID-19 infection and was found deceased at home on 26 December 2020. He had called an ambulance with extreme shortness of breath and apparent hypoxia, but communication difficulties led to the ambulance being sent to the wrong address and him not being located. Concerns included the failure to obtain his correct address, insufficient communication with his ex-partner, and failure to escalate the matter or review the original call when he could not be found.

    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 establish and verify the correct address during emergency call handling

    Wider context from the report

    “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

    Source location

    STEVE MARTIN BRIAN COOKE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the 111-service requirement for callers to provide and confirm the ambulance address through an Operational Bulletin.

    Verbatim wording from the response

    “It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.”

    Source location

    2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
    Page 1 · response
    Published 12 August 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.

    Verbatim wording from the response

    “2. Our process upon a patient not being found by crew on scene”

    Source location

    2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
    Page 2 · response
    Published 12 August 2021

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    David Jonathon Jukes · 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

    David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

    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 use all available means to locate patients requiring assessment

    Wider context from the report

    “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance. There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk. ”

    Source location

    David Jonathon Jukes · 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

    Use a clinical-record communication-preference field to support contact with patients through appropriate channels.

    Verbatim wording from the response

    “We sincerely apologise for this matter. The matter of communication preferences is being addressed by the Trust in that we now have a communication preference field within the clinical record RIO.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2019

    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

    Care and treatment concerns are largely for provider organisations to resolve.

    Verbatim wording from the response

    “2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 26 July 2019

    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

    Local NHS agencies are expected to address the report’s local concerns.

    Verbatim wording from the response

    “Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.”

    Source location

    2019-0220-Response-by-NHS-England
    Page 1 · response
    Published 26 July 2019

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Gary William Million · 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

    Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure 111 and ambulance dispatch staff know and are trained in procedures for locating seriously ill patients with incomplete whereabouts information

    Wider context from the report

    “2. No 111/ambulance dispatch staff knew of or had been trained about the correct procedure to be adopted when trying to locate a potentially seriously ill patient when they had incomplete information as to that persons whereabouts. In short, they did not know how to obtain the callers address. Despite the considerable and well intentioned efforts of a number of people working in the call centre, these individuals failed to locate the deceased’s home address and as a result there was an inordinate delay before the ambulance crew were able to attend the deceased’s property. ”

    Source location

    Gary William Million · 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