Recurring concern

Unreliable emergency access arrangements for responders

First to latest report 1 Apr 2014 — 20 Feb 2026

Reports that mention this concern
14
Times this concern has been raised
15
Stated actions linked to this concern
21

What this concern includes

Includes failures of dedicated arrangements that enable emergency responders to locate, plan access to and safely reach an incident, including hazardous or impracticable access routes and inadequate integrated electronic aids for location, route planning or safe passage.

What is not included
  • Excludes ambulance-only access failures where the concern is confined to ambulance crews gaining entry to care or emergency-treatment premises.
  • Excludes emergency forced-entry arrangements concerning lawful entry into enclosed premises where the shared issue is authority or responsibility for forced entry rather than reaching the incident location.
  • Excludes generic emergency response, dispatch, communication or equipment failures that do not directly impair responder access to the incident location.
  • Excludes ordinary public access, pedestrian routes or workplace access hazards without an emergency-responder access function.

Reports and published responses 14 reports

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

  1. Inner North London

    AI-generated summary

    Sean Perry WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving 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 provide the transport vehicle location to emergency services

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Lancashire and Blackburn with Darwen

    AI-generated summary

    Brody O'Brien · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 7 October 2025, Brody O'Brien, aged 12, died after being found hanging at a redacted location in Rochdale. Concerns included that the area remained unsecured and could be accessed to secure a ligature, and that emergency services faced difficult and treacherous access while carrying equipment.

    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

    Unsafe and difficult emergency access to the location

    Wider context from the report

    “(2) Emergency services found access to the ████████ particularly with their equipment, difficult and treacherous. They had to scale a wall and once inside, the ground was very uneven and dangerous posing a significant risk. ”

    Source location

    Brody O'Brien · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Access to Sunnyside Works is suitable and safe for securing works, contrary to the owner's assertion that it is not.

    Verbatim wording from the response

    “The Council has not accepted this position. The Council has been in communication with the owner of the Albert Mill site and they have confirmed that they are agreeable to ████████ taking access over their land to his property in order to carry out the securing of the building. This has been relayed to ████████ but he does not accept that access is suitable or safe. This is also not accepted by the Council.”

    Source location

    2026-0084 - Response from Rossendale Borough Council
    Page 1 · response
    Published 13 February 2026

    Open published response

  3. Inner North London

    AI-generated summary

    Derrick Frederick Tully · 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

    Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.

    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 provide emergency access to the flat for carers and emergency services

    Wider context from the report

    “Derrick required carers twice a day. He was also given a pendant alarm for emergencies. However, no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat. This was raised repeatedly by his family, carers and other professionals. ”

    Source location

    Derrick Frederick Tully · 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

    Inform the workforce about considering property access risks and contingency planning, including the role of key safes.

    Verbatim wording from the response

    “Islington Council recognise the important role key safes can play in managing risk to individuals, as well the importance of resident consent, risk management and promoting independence and strength. In response to the PFD Notice Islington Council will inform the workforce through the Principal Social Worker the importance of considering access to people’s property in the event of risk, as well as the importance of contingency planning. In addition, Islington Council will undertake a review of its Key safe Policy which will include the factors to be considered when deciding to install.”

    Source location

    Response from Islington Council
    Page 3 · response
    Published 31 March 2025

    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 the Key Safe Policy, including factors for deciding whether to install a key safe.

    Verbatim wording from the response

    “Islington Council recognise the important role key safes can play in managing risk to individuals, as well the importance of resident consent, risk management and promoting independence and strength. In response to the PFD Notice Islington Council will inform the workforce through the Principal Social Worker the importance of considering access to people’s property in the event of risk, as well as the importance of contingency planning. In addition, Islington Council will undertake a review of its Key safe Policy which will include the factors to be considered when deciding to install.”

    Source location

    Response from Islington Council
    Page 3 · response
    Published 31 March 2025

    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 access assessment and telecare emergency contacts were considered sufficient contingencies instead of immediate keysafe installation.

    Verbatim wording from the response

    “ASC acknowledge that there was no keysafe in place, when Reablement support commenced. Mr Tully was assessed as being able to provide access to the property. This assessment would have been made in the context of Islington Council’s ASC practice model for promoting strengths-based practice and that Mr Tully had the mental capacity to make a decision about how he supported access to his property.”

    Source location

    Response from Islington Council
    Page 3 · response
    Published 31 March 2025

    Open published response

  4. Black Country

    AI-generated summary

    Mr David WELLINGTON · 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

    Mr David Wellington died at the scene after being struck by a reversing Renault box van while he was a pedestrian on a service road in Walsall on 12 December 2023. The concerns included the absence of a designated pedestrian route, road markings, pedestrian separation, warning signs and a speed limit, as well as obstructions affecting pedestrian visibility and emergency-service access.

    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 emergency-service access to the service road

    Wider context from the report

    “5. The manual operation of the barrier coupled with the obstructions in the service road itself present a risk to the ability of emergency services (Fire & Ambulance) to access the service road and operate effectively within the service road area if needed. The police investigation noted that the skip and bins had to be moved out of the way on the day of the incident involving Mr Wellington to make room for the emergency services. In my view this presents a risk of future deaths. ”

    Source location

    Mr David WELLINGTON · 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

    Alter trade-waste collections so crews access the rear of shops, collect bins there, and leave the service road clear.

    Verbatim wording from the response

    “Waste bins In the absence of anywhere, other than the service road, more suitable to leave the trade waste bins for collection, the council is in the process of altering the procedure for collecting trade waste from the rear of the shops. The proposal is in the future the crew of the waste collection lorry will be provided with a key to the barrier across the service road. The waste collection lorry will reverse along the service road to the rear of the shops. Any trade waste bins will be collected from the rear of the shops. The waste collection lorry will then drive forwards along the service road towards Bloxwich Road, locking the barrier behind it. There will thus be no need for trade waste bins to be left on the carriageway of the service road.”

    Source location

    2024-0233 Response from Walsall MBC
    Page 8 · response
    Published 9 May 2024

    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

    Notify shop and maisonette lessees that skips are prohibited on the service road and require written council consent for any placement.

    Verbatim wording from the response

    “Skips As can be seen from the opening paragraphs of this response the council owns the service road but the occupiers of adjoining premises have private rights of way along it. Those rights of way allow for people to pass and re-pass along the service road. They do not give anyone the right to place a skip on the service road. A wrongly placed skip could obstruct the rights of way of others along the service road. The council does, however, recognise that there are occasions when skips do need to be placed near buildings. The council has thus written to all of the lessees of the shops and the maisonettes facing Leamore Lane to remind them that they are not permitted to place skips on the service road.”

    Source location

    2024-0233 Response from Walsall MBC
    Page 8 · response
    Published 9 May 2024

    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

    Complete consideration of removing the barrier and determine that removal would exacerbate access obstruction.

    Verbatim wording from the response

    “Whilst the council recognises that the presence of the barrier poses an obstruction to the private rights of way along the service road, that obstruction was requested by those entitled to have vehicular access to their premises along the service road. The reality is that the barrier poses less of an obstruction to vehicular access than that caused by the unauthorised parking of vehicles behind the shops. The council has carried out the exercise of considering whether the concerns set out in the Prevention of Future Deaths Report could be met by the removal of the barrier. The historical experience of the service road being blocked by unauthorised vehicles has led the council to conclude that the problem of obstruction of access would be exacerbated, rather than lessened, by the removal of the barrier.”

    Source location

    2024-0233 Response from Walsall MBC
    Page 4 · response
    Published 9 May 2024

    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

    Retaining the barrier is considered preferable because removing it would worsen obstruction caused by unauthorised vehicle parking.

    Verbatim wording from the response

    “Whilst the council recognises that the presence of the barrier poses an obstruction to the private rights of way along the service road, that obstruction was requested by those entitled to have vehicular access to their premises along the service road. The reality is that the barrier poses less of an obstruction to vehicular access than that caused by the unauthorised parking of vehicles behind the shops. The council has carried out the exercise of considering whether the concerns set out in the Prevention of Future Deaths Report could be met by the removal of the barrier. The historical experience of the service road being blocked by unauthorised vehicles has led the council to conclude that the problem of obstruction of access would be exacerbated, rather than lessened, by the removal of the barrier.”

    Source location

    2024-0233 Response from Walsall MBC
    Page 4 · response
    Published 9 May 2024

    Open published response

  5. Dorset

    AI-generated summary

    Tarik Roger Drakes · 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

    Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.

    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

    Unavailability of a functioning out-of-hours emergency access route

    Wider context from the report

    “1. During the inquest evidence was heard that: i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely. ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions. iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please. iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time. v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns. vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment. vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner. viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead. 2. I have concerns with regard to the following: i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents. ”

    Source location

    Tarik Roger Drakes · 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

    Remind customers across the housing stock how to contact out-of-hours services and improve related signage.

    Verbatim wording from the response

    “We have discussed OOH arrangements with customers again and asked that they contact OOH Repairs and Maintenance or NRT if there are any incidents during the evenings and weekends. We will also be doing more work to remind customers of how to get in touch out of hours across all of our stock. Signage has been further improved in the reception area of Dorset Lodge to this effect.”

    Source location

    Response from BCHA
    Page 7 · response
    Published 22 March 2023

    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

    Free access to the building cannot be provided for emergency services because of security requirements; remote or resident-enabled access is used instead.

    Verbatim wording from the response

    “As with all HMO’s and unstaffed properties, customers can let emergency services in if needed. There is a pad on the front door to call through to other homes. It would not be possible to allow free access into the building for security reasons. This would not be a unique situation for emergency services and is reflective of other HMOs/Apartments without staff or security on site. Dorset Lodge is able to be opened remotely by NRT also if they are contacted and are available.”

    Source location

    Response from BCHA
    Page 7 · response
    Published 22 March 2023

    Open published response

  6. Milton Keynes

    AI-generated summary

    William VICKERS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

    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 unobstructed ambulance access through all security gates

    Wider context from the report

    “During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident. Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient. The present system in my view puts prisoners’ lives at risk. ”

    Source location

    William VICKERS · 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

    Update emergency vehicle contingency plans with immediate ambulance notification, gate staffing, additional OSG support, proportionate searching, and information sharing to prevent access delays.

    Verbatim wording from the response

    “Since Mr Vickers’ inquest the contingency plans at HMP Woodhill have been updated to ensure that there are no delays to the process of receipt of any emergency vehicle, including ambulances during night state. When a code red or blue is called, the control room contacts South Central Ambulance Service (SCAS) immediately. When this occurs during night state, members of staff report to the prison gate to await the arrival of the ambulance, and to assist the responding dog handler with opening the gates to the units.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 9 September 2019

    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 all Custodial Managers an opportunity to participate in a live test of emergency vehicle receipt arrangements.

    Verbatim wording from the response

    “All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 9 September 2019

    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 establishment-based training for OSGs on emergency vehicle receipt arrangements, with completion required for all OSGs by the end of 2019.

    Verbatim wording from the response

    “All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

    Source location

    2019-0255-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 9 September 2019

    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

    Establish a joint prison access process to provide ambulance crews with timely access to patients and identify expected emergency resources.

    Verbatim wording from the response

    “2. Access to the prisoner (patient).”

    Source location

    2019-0255-South-Central-Ambulance-Service-NHS-Trust
    Page 4 · response
    Published 9 September 2019

    Open published response

  7. Inner North London

    AI-generated summary

    Tony Goodridge · 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

    Tony Goodridge died after being found unresponsive in his flat following a fire on 19 November 2018; the medical cause was recorded as inhalation of fire fumes and airway burns. The principal concerns were that there was no smoke alarm in the property and that parked vehicles made it more difficult for the London Fire Brigade to reach the property.

    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

    Obstructed emergency access to the property by parked vehicles

    Wider context from the report

    “(2) The London Fire Brigade had some difficulty reaching the property due to parked vehicles in the vicinity. ”

    Source location

    Tony Goodridge · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Yorkshire Eastern

    AI-generated summary

    Joshua Lee Edwards · 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

    Joshua Lee Edwards, aged 19, became unwell in Leeds after taking ecstasy and cocaine and died in hospital on 15 May 2017 despite treatment. The ambulance was delayed by road closures for the Leeds 10K run, and concerns were raised that repeated calls from police did not lead to escalation and that ambulance crews were unclear about crossing road-closure signs in an emergency.

    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 provide road signs that preserve emergency vehicle access at designated crossing points

    Wider context from the report

    “(4) Road closure signs at such designated crossing points should be replaced by signs indicating ‘Access to emergency vehicles only’ or equivalent wording. ”

    Source location

    Joshua Lee Edwards · 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 emergency vehicle access during public events

    Wider context from the report

    “(1) The ambulance despatched to the scene encountered roads closed for the Leeds 10K run that day. It then navigated a route around the course, thus encountering a delay in reaching the casualty. The Police Officers at the scene telephoned three times to ask where the ambulance was but this did not result in the situation being escalated in the control room at Yorkshire Ambulance Service. ”

    Source location

    Joshua Lee Edwards · 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

    Continually review event road closures to ensure they remain appropriate, minimal and safe.

    Verbatim wording from the response

    “Whilst some road closures are inevitable with the events in the city, we are also continually reviewing these to make sure they are appropriate, kept to a minimum and are as safe as possible.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 3 · response
    Published 2 March 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

    Replacing road-closure signs could weaken their prohibition and create safety risks; existing signs should remain under current legislation with controlled emergency access measures.

    Verbatim wording from the response

    “Road closure signs during events are placed for the safety of event participants and road users alike. In the current climate of vehicle incursion we would not seek to weaken their prohibition of vehicles by allowing anyone to confuse or misinterpret the message to suggest that any form of access is permitted. In doing so there will always be road users who interpret the signs to their advantage. In discussions with emergency services and traffic regulation colleagues I feel it is preferable to maintain the road closure signing as it is set out in the Traffic Signs Regulations and General Directions legislation and take other measures such as those described above. This will provide authority to those who legitimately need access in a controlled way. This will ensure that any delays to genuine emergencies are minimised and the safety of the event participant is not compromised.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 3 · response
    Published 2 March 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

    Existing event management plans, designated crossing points and trained marshals sufficiently address emergency vehicle access and temporary event stoppages.

    Verbatim wording from the response

    “Every major event such as the half-marathon and Leeds 10k run includes an Event Management Plan which sets out the process for emergency responses, emergency vehicle access and the training of Marshalls. Emergency routes are agreed with emergency services during the planning for each event. Specific locations to cross the routes are designated. These are used wherever possible. Other locations can be used under the control of Event Control. All road closure points are staffed with marshals capable of assisting access and halting events in the case of an emergency.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 2 · response
    Published 2 March 2019

    Open published response

  9. Bedfordshire and Luton

    AI-generated summary

    MAVIS JEANNE REVES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 1 July 2017, Mavis Jeanne Reves pulled her Careline cord because she had a dry mouth and was struggling to breathe. Paramedics reached her flat after delays involving the building’s automated entry system and key safe, and performed CPR. The concerns included limitations of the analogue Careline system, delays in emergency access and connection time, and difficulties identifying the master key.

    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 analogue Careline system to support concurrent emergency access and calls

    Wider context from the report

    “(1) At the Inquest it was revealed that there are 4 ways a non-resident can enter the building: (a) By entering the room number on the keypad (b) By using a code (c) By pressing 2 buttons, namely “clear” and then “call” (d) By being allowed in by a resident that was passing through the entrance The deceased did not answer the call; the code was not available to the paramedic, who had arrived before it was forwarded to his car’s computer. In any event that which arrived was probably not the correct code. The “call” button is supposed to connect to the Emergency Call Centre, but will not connect if the Careline has been pulled. In this case, the fact that the deceased was still talking to the Careline Operator meant that option (c) above was not available to the paramedic. This is because the system in place is an analogue system and there is only one line going from the building to Careline. Evidence was heard that only 3% of Careline calls result in 999 being called. The remaining 97% are non-urgent calls, accidental calls and calls by residents who are lonely. This means that access using option (c) could be deprived by anyone else in the building using the system. Further it means that once one resident is using the system that no other resident can call the Careline, even if there is an emergency. The scenario of a resident calling the Careline in an emergency and staying on the line is understandable and cannot be that unusual. It appears that a digital system would avoid these problems. It is understood that for a digital system to be installed the residents must agree to fund it, and that would then form part of the service charge. My concern is twofold. First, do the residents know of the limitation within the Careline System currently installed? Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. (2) The Inquest heard that the analogue system takes 90 seconds to connect. The reason for this is because it is also sending data relating to the Careline Operator’s Terminal. A digital system would reduce that to 4 seconds. My concern again is whether the residents know this. In cases where promptness is important 90 seconds can be the difference between life and death. ”

    Source location

    MAVIS JEANNE REVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. West Yorkshire Eastern

    AI-generated summary

    Paul David Whitehead · 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

    Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

    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 emergency-site access and wayfinding to expedite Ambulance arrival

    Wider context from the report

    “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty. (2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager. (3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation. (4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes. These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur. Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty. ”

    Source location

    Paul David Whitehead · 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

    Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.

    Verbatim wording from the response

    “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.

    Verbatim wording from the response

    “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    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 flashlights in the security cabin for lookouts to attract emergency services’ attention.

    Verbatim wording from the response

    “The revised Emergency procedures document now clearly states that the “lookouts” must be stationed at all of the access points to the site. Additionally we are ensuring that flash lights are kept in the security cabin which the lookouts are required to use as an aid for attracting the attention of the emergency services.”

    Source location

    Paul-Whitehead-Response
    Page 2 · response
    Published 14 December 2015

    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