Recurring concern

Unreliable ambulance stand-down decisions

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First reported 1 Oct 2013•Latest report 25 Jun 2018

Definition

What this concern includes

Includes failures in the dedicated ambulance stand-down or stand-off decision process, including decision criteria, consideration of vulnerability and clinical risk, managerial or clinical oversight, notification, escalation and review when support may be delayed.

Not included

Excludes ordinary ambulance attendance delays, dispatch capacity and response-time failures where no deficient stand-down or stand-off decision is identified.
Excludes failures to communicate ambulance dispatch status or expected arrival after an appropriate attendance decision has been made.
Excludes clinical treatment, hospital handover and patient care after ambulance attendance has occurred.
Excludes generic escalation, communication or management deficiencies unless they directly concern an ambulance stand-down or stand-off decision.

Reports: 3
Individual concerns: 4
Date range: 2013–2018
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

South Central Ambulance Service NHS Foundation Trust1

South East Coast Ambulance Service NHS Foundation Trust1

Yorkshire Ambulance Service NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

25 Jun2018
West Sussex
Concerns raised1
1. Lack of clinical oversight of ambulance stand-down decisions
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Require ambulance stand-down decisions to undergo two-step verification by a Dispatch Team Leader or Clinical Navigator.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
AI-generated summary

MARGARET STEMP · 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

Margaret Stemp, aged 91, was found deceased on 28 December 2017 after she and her sister had fallen and remained on the floor for over seven hours before police assistance. The inquest concluded that she died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention. Concerns included insufficient ambulance resources, reliance on police for welfare support, failure to recognise worsening circumstances, and no clinical oversight of the decision to stand down the ambulance response.

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 clinical oversight of ambulance stand-down decisions
Wider context from the report
“(4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend. ”
Source location
MARGARET STEMP · 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
Require ambulance stand-down decisions to undergo two-step verification by a Dispatch Team Leader or Clinical Navigator.

Verbatim wording from the response
“As a result of this incident, the procedure for standing down an ambulance has now been changed. A Support Call Taker can no longer stand down an ambulance. A two-step verification process has been introduced whereby they must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down.”

Source location
2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 2018
Open published response
8 Sep2014
South Yorkshire (Western)
Concerns raised2
1. Lack of manager notification when a crew unilaterally stands off and support is likely to be delayed
2. Failure of the stand-off process to ensure automatic consideration of all alternative support methods
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Implement the Joint Decision Model with manager review, phased staff training and awareness sessions for stand-off decisions.
  Stated by Yorkshire Ambulance Service NHS TrustStated in progress
2. Action
  Escalate delayed Red 1 and Red 2 incidents to Clinical Duty Managers for further clinical assessment.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
3. Action
  Update the Safety and Security Policy and strengthen frontline training on dynamic risk assessment for lone responding.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
1. Action
  Remind Emergency Operations Centre staff to consider all available responder and emergency-service support options in stand-off situations.
  Stated by Yorkshire Ambulance Service NHS TrustStated completed
AI-generated summary

Anthony Offord · 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

Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.

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 manager notification when a crew unilaterally stands off and support is likely to be delayed
Wider context from the report
“(2) That where crew make a unilateral decision to stand off there is no requirement for a manager to be informed, even when there is likely to be a delay in the provision of support. ”
Source location
Anthony Offord · Prevention of Future Deaths report
Page 3 · 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 of the stand-off process to ensure automatic consideration of all alternative support methods
Wider context from the report
“(3) That there is no system to ensure that all alternative methods of support are automatically considered when a stand-off occurs, not simply a double crewed ambulance. ”
Source location
Anthony Offord · 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
Implement the Joint Decision Model with manager review, phased staff training and awareness sessions for stand-off decisions.

Verbatim wording from the response
“The Trust is implementing a change in current practice within the EOC which is based around the Joint Decision Model (JDM). This is the standard decision decision making model used across the police service in the United Kingdom. The model seeks to bring together the available information pertinent to the decision, reconcile objectives and then enable effective decisions to be made.”

Source location
2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Page 2 · response
Published 8 September 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
Escalate delayed Red 1 and Red 2 incidents to Clinical Duty Managers for further clinical assessment.

Verbatim wording from the response
“All Red 1 and Red 2 incidents (whether this relates to a stand-off situation or not) where the estimated time of arrival is greater than the response are actively listened to by clinicians within the clinical hub. Where these delays have been identified they are now escalated to a CDM for further clinical assessment.”

Source location
2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Page 2 · response
Published 8 September 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
Update the Safety and Security Policy and strengthen frontline training on dynamic risk assessment for lone responding.

Verbatim wording from the response
“The Trust has, however, reviewed and updated the Safety and Security Policy, which covers the process relevant to lone responding. Training and education about the dynamic risk assessment process for frontline responders has been strengthened and awareness about the JDM being implemented in EOC is planned prior to its implementation. Using the JDM will ensure a standardised framework is utilised for all stand-off decisions. Where stand off decisions are made they will be based on dynamic assessment relating to that individual incident with appropriate escalation as required.”

Source location
2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Page 3 · response
Published 8 September 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
Remind Emergency Operations Centre staff to consider all available responder and emergency-service support options in stand-off situations.

Verbatim wording from the response
“An information bulletin has been provided to all staff within the EOC to remind them to consider all alternative methods of support in a stand-off situation, including all forms of responders, not just double crewed ambulances, and also, where applicable, other emergency services, such as the police.”

Source location
2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Page 3 · response
Published 8 September 2014
Open published response
1 Oct2013
Oxfordshire
Concerns raised1
1. Failure to communicate whether ambulance staff should stand down or stand back
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

DAVID LESLIE SELMAN · 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 Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause 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 communicate whether ambulance staff should stand down or stand back
Wider context from the report
“5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back. 5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem. ”
Source location
DAVID LESLIE SELMAN · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of clinical oversight of ambulance stand-down decisions

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Lack of manager notification when a crew unilaterally stands off and support is likely to be delayed

Failure of the stand-off process to ensure automatic consideration of all alternative support methods

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to communicate whether ambulance staff should stand down or stand back

Actions described in response 1

Actions described in response 4