Recurring concern

Unreliable ambulance emergency escalation and contingency arrangements

First to latest report 20 Apr 2016 — 6 Jan 2026

Reports that mention this concern
5
Times this concern has been raised
7
Stated actions linked to this concern
8

What this concern includes

Includes protocols and operational arrangements for clinical escalation, expedited response, alternative emergency-service assistance and maintenance of safe emergency coverage when ordinary ambulance allocation is inadequate.

What is not included
  • Ordinary ambulance response delays or capacity shortages where escalation and contingency controls are reliable
  • Hospital handover and treatment after an effective response
  • Other agencies' internal failures after a clear and appropriate assistance request

Reports and published responses 5 reports

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

  1. Greater Lincolnshire

    AI-generated summary

    Robert Shaun GRACEY · 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

    Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.

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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

    Lack of an ABD protocol between police forces and the local ambulance service

    Wider context from the report

    “1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such protocol in Lincolnshire. ”

    Source location

    Robert Shaun GRACEY · 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

    Work with EMAS and the Clinical Governance Forum to implement an ABD joint-working policy.

    Verbatim wording from the response

    “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.”

    Source location

    2026-0004 - Response from Lincolnshire Police
    Page 1 · response
    Published 8 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

    Share learning from the coronial process with EMAS to support ABD guidance development and implementation.

    Verbatim wording from the response

    “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.”

    Source location

    2026-0004 - Response from Lincolnshire Police
    Page 1 · response
    Published 8 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

    Work with EMAS and Forum partners to develop and align ABD practices and training, including response times and restraint practices.

    Verbatim wording from the response

    “Lincolnshire Police will continue to work with EMAS and partners within the Forum in order to develop and align practices and training to deal with ABD, response times, and restraint practices.”

    Source location

    2026-0004 - Response from Lincolnshire Police
    Page 2 · response
    Published 8 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

    Continue participating in the Police Regional Clinical Governance Forum to align ABD training and response protocols.

    Verbatim wording from the response

    “The Trust currently operates across six counties within the East Midlands, creating logistical hurdles when ensuring policies and response protocols are consistent across multiple counties and multiple police forces. The Trust will, however, continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD.”

    Source location

    Response from East Midlands Ambulance Service NHS Trust
    Page 3 · response
    Published 8 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

    Continue working with regional police forces and health partners to explore a single joint operational framework for ABD management.

    Verbatim wording from the response

    “The Trust will also continue to work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management.”

    Source location

    Response from East Midlands Ambulance Service NHS Trust
    Page 3 · response
    Published 8 January 2026

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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

    East Midlands Ambulance Service is responsible for responding directly to the concerns and revising relevant clinical presentation protocols with system partners.

    Verbatim wording from the response

    “NHS England’s Midlands regional colleagues have reached out to Derby and Derbyshire Integrated Care Board (ICB) who has advised that East Midlands Ambulance Service will be responding directly to the concerns you raised. The Trust has confirmed that, as part of the learning and actions arising from this process, a review of all existing Memorandums of Understanding (MOUs) is underway to ensure appropriate governance arrangements are in place for each agreement. Through their Mental Health lead, the Trust is also working collaboratively with system partners to revise the relevant clinical presentation protocols.”

    Source location

    Response from NHS England
    Page 6 · response
    Published 8 January 2026

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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

    EMAS is responsible for leading the joint ABD policy because the medical response is a crucial element and EMAS is best placed to lead.

    Verbatim wording from the response

    “All Forces in the East Midlands contribute to the work of the Forum. The Forum as a whole decided that the basis of the work should be carried out by EMAS given that the medical response was a crucial element of the policy and therefore EMAS were best placed to lead upon it. The joint working policy will therefore inform the response on the part of other Police Forces within the East Midlands.”

    Source location

    2026-0004 - Response from Lincolnshire Police
    Page 2 · response
    Published 8 January 2026

    Open published response

  2. Gwent

    AI-generated summary

    Dorothy Anne Jones · 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

    Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.

    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

    Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines

    Wider context from the report

    “3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited. However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines. ”

    Source location

    Dorothy Anne Jones · 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

    Conduct secondary triage of waiting patients, including Amber 1 calls, through the Clinical Support Desk to reassess or confirm priority.

    Verbatim wording from the response

    “In the live environment, WAST regularly undertakes more detailed clinical assessments of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the correct priority for patients. This process, known as secondary triage or consultation is led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control room nurses, paramedics, advanced paramedics, and mental health practitioners.”

    Source location

    Response from Welsh Ambulance Services NHS Trust
    Page 2 · response
    Published 24 January 2023

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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

    Use welfare calls and Clinical Support Desk procedures to reassess waiting patients and upgrade calls when clinical conditions or prolonged waits warrant it.

    Verbatim wording from the response

    “A copy of the CSP is attached for your reference and as you will see this provides details of when welfare calls should be made. These calls are made to reassess the patient’s clinical condition, if any changes are reported.”

    Source location

    Response from Welsh Ambulance Services NHS Trust
    Page 3 · response
    Published 24 January 2023

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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

    Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.

    Verbatim wording from the response

    “I note you have also written to ████████, Chief Executive of the Welsh Ambulance Services Trust and I would expect him to respond on the detail of the concerns you raised as these relate to operational matters and are best addressed by the Trust. I can, however, outline the actions being taken by the Welsh Government to drive national and local improvement in the delivery of safe and timely ambulance services.”

    Source location

    Response from Minster for Health and Social Services
    Page 1 · response
    Published 24 January 2023

    Open published response

  3. Gateshead and South Tyneside

    AI-generated summary

    MAUREEN WHARTON · 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

    Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.

    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 protocol enabling personnel to initiate responses beyond ambulance allocation

    Wider context from the report

    “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process. It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls. Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented. An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise. b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger. There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent. ”

    Source location

    MAUREEN WHARTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cheshire

    AI-generated summary

    Gladys Esme FURNIVAL (known as Esme FURNIVAL) · 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

    Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.

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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

    Lack of provision to provide updates to other emergency services during significant ambulance delays

    Wider context from the report

    “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them. ”

    Source location

    Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report
    Page 1 · 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

    Lack of provision to utilise other emergency services during significant ambulance delays

    Wider context from the report

    “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them. ”

    Source location

    Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. South Wales Central

    AI-generated summary

    Ronald Hamer · 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

    Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.

    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 clear planning and direction for maintaining and delivering ambulance services

    Wider context from the report

    “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves. ”

    Source location

    Ronald Hamer · Prevention of Future Deaths report
    Page 1 · 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 maintain ambulance service delivery during significant call volumes

    Wider context from the report

    “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves. ”

    Source location

    Ronald Hamer · 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

    Develop an action plan addressing the Regulation 28 improvement requirements.

    Verbatim wording from the response

    “I am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased). I would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the key actions for improvement. Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”

    Source location

    2016-0149-Response-by-Welsh-Ambulance-Services-NHS-Trust
    Page 1 · response
    Published 20 April 2016

    Open published response

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

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Data last updated 7 September 2026