Recurring concern

Unreliable interpretation of cardiac electrical recordings

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First reported 29 Nov 2016•Latest report 9 May 2025

Definition

What this concern includes

Includes failures of clinical interpretation of cardiac electrical recordings, including Holter recordings, 12-lead ECGs and comparable traces, where abnormalities, rhythms or clinically significant findings are missed, misunderstood or not reliably identified.

Not included

Excludes failures limited to obtaining, performing or technically recording an ECG or Holter study when interpretation is not deficient.
Excludes delays in specialist review or referral where the interpretation itself is reliable and timeliness is the only concern.
Excludes generic clinical competence, training or communication deficiencies unless they directly concern interpretation of cardiac electrical recordings.
Excludes interpretation of unrelated diagnostic tests or physiological measurements, such as CTG traces, blood glucose readings or imaging, unless the assertion specifically concerns cardiac electrical recordings.

Reports: 6
Individual concerns: 7
Date range: 2016–2025
Stated actions: 19

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 Care3

Health and Care Professions Council2

Barts Health NHS Trust1

Care Quality Commission1

Department for Digital, Culture, Media and Sport1

Faculty of Intensive Care Medicine1

Guy'S and St Thomas' NHS Foundation Trust1

Health Services Safety Investigations Body1

NHS Central East Integrated Care Board1

Northamptonshire Safeguarding Children Partnership1

North West Anglia NHS Foundation Trust1

Pennine Acute Hospitals NHS Trust1

Royal College of Emergency Medicine1

Royal College of Radiologists1

University of Wolverhampton1

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.

9 May2025
Manchester South
Concerns raised1
1. Failure to recognise the significance of 12-lead ECG readings
This report raised 5 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.
Respondent positions 1
1. Position
  Individual NHS Trusts and employers are responsible for staff competence and appropriate protocols following the death, rather than the Department.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jake Samuel Lawler · Prevention of Future Deaths report

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

Report summary

Jake Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community settings.

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 recognise the significance of 12-lead ECG readings
Wider context from the report
“1. The inquest heard evidence that the significance of 12 lead ECG readings are regularly missed or misunderstood by clinicians which means that key warning signs are missed as in Jake’s case. It is unclear if this is a training issue or the way in which the machines report of volume. Without an improvement there will be further avoidable deaths ”
Source location
Jake Samuel Lawler · 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
Individual NHS Trusts and employers are responsible for staff competence and appropriate protocols following the death, rather than the Department.

Verbatim wording from the response
“I note your concerns about training and national guidance. Individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice. We would expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Lawler. I note that Manchester University NHS Foundation Trust has considered how to improve both training and guidance as part of their Safety Improvement Plan, which they have shared with NHSE.”

Source location
2025-0220- Response from Department of Health and Social Care
Page 1 · response
Published 20 May 2025
Open published response
7 Apr2025
Cambridgeshire and Peterborough
Concerns raised1
1. Deficiencies in ECG interpretation
This report raised 21 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.
Respondent positions 1
1. Position
  Individual NHS Trusts and other employers are responsible for ensuring staff remain competent and capable in their areas of practice.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Christian James Gabriel Hobbs · 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

Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

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
Deficiencies in ECG interpretation
Wider context from the report
“POINT L – ECG ANALYSIS Some Issues emerged in evidence on the interpretation of the ECG at 18:10. This again raises concerns. ”
Source location
Christian James Gabriel Hobbs · Prevention of Future Deaths report
Page 20 · 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
Individual NHS Trusts and other employers are responsible for ensuring staff remain competent and capable in their areas of practice.

Verbatim wording from the response
“On points F, K, and L, where you raise issues of workforce levels and training, individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 15 April 2025
Open published response
15 Nov2023
Black Country
Concerns raised2
1. Failure to correctly interpret 12 lead ECGs
2. Lack of further ECG training after identified incorrect interpretation
This report raised 6 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 15
1. Action
  Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.
  Stated by Health Services Safety Investigations BodyStated in progress
2. Action
  Review the exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.
  Stated by Health Services Safety Investigations BodyStated planned
3. Action
  Deliver CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
1. Action
  Deliver ECG recognition and advanced life support sessions with Zoll Medical.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
2. Action
  Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
3. Action
  Deliver an in-person CPD event covering ECG signs and recognition.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
4. Action
  Review ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated in progress
5. Action
  Provide remedial ECG and acute coronary syndrome training to both clinicians through training school.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated planned
6. Action
  Support a clinician’s attendance on a level-six ECG-in-practice university course.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated planned
7. Action
  Review all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.
  Stated by University of WolverhamptonStated completed
8. Action
  Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.
  Stated by University of WolverhamptonStated planned
9. Action
  Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.
  Stated by University of WolverhamptonStated planned
10. Action
  Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.
  Stated by University of WolverhamptonStated in progress
11. Action
  Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.
  Stated by University of WolverhamptonStated planned
12. Action
  Organise continuing professional development ECG masterclasses for registered paramedics.
  Stated by University of WolverhamptonStated planned
Respondent positions 4
1. Position
  Q-wave changes and AVR deflection are included in training but are not significant features of the high-level ECG competency described.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustDisputes the concern
1. Position
  Student placement risks are ameliorated because a registered paramedic supervises students and remains responsible and accountable for patient care.
  Stated by University of WolverhamptonExisting arrangements considered sufficient
2. Position
  There was no evidence of provider-level failure in relation to Miss Lauren Page Smith’s death.
  Stated by Care Quality CommissionDisputes the concern
3. Position
  At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.
  Stated by University of WolverhamptonDisputes the concern
AI-generated summary

Lauren Page Smith · 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

Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.

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 correctly interpret 12 lead ECGs
Wider context from the report
“Some of the concerns I have identified are directed at multiple organisations and some are specific. During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████ 1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics. 2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience. 3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection. 4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg. 5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI. 6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report. 7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information. 8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg. 9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time. 10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time. 11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest. 12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time. 13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time. 14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS. ”
Source location
Lauren Page Smith · Prevention of Future Deaths report
Page 2 · 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 further ECG training after identified incorrect interpretation
Wider context from the report
“Some of the concerns I have identified are directed at multiple organisations and some are specific. During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████ 1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics. 2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience. 3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection. 4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg. 5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI. 6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report. 7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information. 8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg. 9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time. 10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time. 11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest. 12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time. 13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time. 14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS. ”
Source location
Lauren Page Smith · 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
Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.

Verbatim wording from the response
“On 20 December 2023, our Investigations and Insights team held an Intelligence Review Meeting; at this meeting we review all patient safety concerns and insights received into our organisation and consider them for further exploratory work. I would like to assure you that the Regulation 28 Report sent to us was considered in this meeting, along with other information available to us and I can confirm that further exploratory work is being undertaken in relation to the issues raised in your report.”

Source location
Response from Health Services Safety Investigations Body
Page 1 · response
Published 22 November 2023
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 exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.

Verbatim wording from the response
“This exploratory work will be further reviewed by the end of January 2024 when we will consider the scope for an HSSIB investigation into issues related to Paramedic interpretation of ECGs in the community.”

Source location
Response from Health Services Safety Investigations Body
Page 1 · response
Published 22 November 2023
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 CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.

Verbatim wording from the response
“• There was a CPD day at Erdington hub alongside the Research team to provide presentation on STEMI clinical times article on ACS and the new JRCALC update, including the ambulance quality indicators and time from 999 call to inflation of a balloon in a specialist coronary catheter”

Source location
Response from West Midlands Ambulance Service
Page 6 · response
Published 22 November 2023
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 ECG recognition and advanced life support sessions with Zoll Medical.

Verbatim wording from the response
“February 2023”

Source location
Response from West Midlands Ambulance Service
Page 6 · response
Published 22 November 2023
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 evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.

Verbatim wording from the response
“• Evening training session on ECGs and Resus skills delivered”

Source location
Response from West Midlands Ambulance Service
Page 7 · response
Published 22 November 2023
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 an in-person CPD event covering ECG signs and recognition.

Verbatim wording from the response
“June 2023”

Source location
Response from West Midlands Ambulance Service
Page 7 · response
Published 22 November 2023
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 ECG cases and disseminate the resulting learning through staff briefings and clinical communications.

Verbatim wording from the response
“September 2023”

Source location
Response from West Midlands Ambulance Service
Page 7 · response
Published 22 November 2023
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 remedial ECG and acute coronary syndrome training to both clinicians through training school.

Verbatim wording from the response
“Both the clinicians are booked to attend training school for remedial training on the 1 December 2023. In addition to this ████████ will be meeting with the Trust’s Consultant Paramedic who is the Head of Clinical Care, ████████ to review and reflect on the ECG abnormalities as part of an additional self reflection request.”

Source location
Response from West Midlands Ambulance Service
Page 8 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Support a clinician’s attendance on a level-six ECG-in-practice university course.

Verbatim wording from the response
“Since the incident ████████ has also requested to attend a level 6 university course to further her knowledge on ECG’s. ████████ has been approved and supported by WMAS to attend a level 6 ECG in practice course, commencing in January 2024.”

Source location
Response from West Midlands Ambulance Service
Page 8 · response
Published 22 November 2023
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 all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.

Verbatim wording from the response
“The University understands and accepts without reservation that its training must be effective. We have reviewed all of the ECG training and assessment that takes place on the programme and are confident that our teaching fully covers the abnormalities found in the ECG in this case, the pathological implications of such findings, and the appropriate course of action to be taken.”

Source location
Response from University of Wolverhampton
Page 4 · response
Published 22 November 2023
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
Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.

Verbatim wording from the response
“▪ Evidence from the case will be presented to students to exemplify the potential harm from inadequate understanding of the ECG and the implications for the patient – we would welcome a copy of the ECG if this is possible”

Source location
Response from University of Wolverhampton
Page 4 · response
Published 22 November 2023
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
Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.

Verbatim wording from the response
“▪ Interpretation of 12-lead ECGs will be incorporated into one or more of the Objective Structured Clinical Examinations that students sit throughout their programme. This will supplement rather than replace the current assessments in practice.”

Source location
Response from University of Wolverhampton
Page 4 · response
Published 22 November 2023
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
Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.

Verbatim wording from the response
“▪ Members of the paramedic team are liaising with local coronary care units to obtain anonymised 12-lead ECG readings from real patients to further enhance the teaching”

Source location
Response from University of Wolverhampton
Page 4 · response
Published 22 November 2023
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
Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.

Verbatim wording from the response
“▪ A 12-lead ECG interpretation workbook will be added to the virtual learning environment for completion by students. Students who do not complete the activity will be followed up by their personal academic tutor”

Source location
Response from University of Wolverhampton
Page 5 · response
Published 22 November 2023
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
Organise continuing professional development ECG masterclasses for registered paramedics.

Verbatim wording from the response
“▪ The University will organise continuing professional development ECG masterclasses to offer to registered paramedics”

Source location
Response from University of Wolverhampton
Page 5 · response
Published 22 November 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
Q-wave changes and AVR deflection are included in training but are not significant features of the high-level ECG competency described.

Verbatim wording from the response
“Response Q wave changes and AVR deflection does feature in our training but is not a significant feature, as this is high level ECG competency. The ECG auto diagnostic did identify an abnormal ECG and this should have been acted upon.”

Source location
Response from West Midlands Ambulance Service
Page 7 · response
Published 22 November 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
Student placement risks are ameliorated because a registered paramedic supervises students and remains responsible and accountable for patient care.

Verbatim wording from the response
“████████ commenced her education at the University in June 2022, and is not due to complete her studies until January 2024. It is important to emphasise, that ████████ is not a registered paramedic and will not be eligible to apply for professional registration until such time as she has met all of the outcomes of her current programme of study. As a student, ████████ does not have all of the competencies and skills of a registered paramedic so would be working with a practice educator who is there to support and supervise her as she develops those competencies and skills. It is not expected that she would be making independent decisions on patient care whilst in her role as a student paramedic. The practice educator will always have the ability to override the decision of a student should they deem the proposed course of action to be sub-optimal for the patient.”

Source location
Response from University of Wolverhampton
Page 2 · response
Published 22 November 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
There was no evidence of provider-level failure in relation to Miss Lauren Page Smith’s death.

Verbatim wording from the response
“Having carefully reviewed the information the trust has provided, we have concluded there is no evidence of provider level failing in relation to Miss Lauren Page Smith’s death. However, we did identify concerns that supported our inspection findings in relation to the serious incident investigation process, and in particular, the timeliness around addressing the training needs of the staff involved with Miss Lauren Page Smith’s care.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 22 November 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
At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.

Verbatim wording from the response
“It should also be noted that on the 6 January 2023, ████████ was working as an employee of WMAS and was not there in her student capacity. ████████ was working within the remit of an associate ambulance practitioner.”

Source location
Response from University of Wolverhampton
Page 2 · response
Published 22 November 2023
Open published response
21 Mar2018
Manchester South
Concerns raised1
1. Failure to consider ECG machine printouts in clinical interpretation and judgment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Administrative lead-employer responsibilities exclude the host hospital’s quality of care, training and day-to-day trainee supervision.
  Stated by NHS Northern Care Alliance NHS GroupOutside remit
1. Position
  The host hospital is responsible for care quality and trainee supervision and has the power to address the reported concerns.
  Stated by NHS Northern Care Alliance NHS GroupRedirects responsibility
2. Position
  The administrative lead employer cannot implement changes at the host hospital because it lacks authority over care delivery and supervision.
  Stated by NHS Northern Care Alliance NHS GroupUnable to act
AI-generated summary

Barbara Johnson · 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

Barbara Johnson was detained under Section 3 of the Mental Health Act and admitted to the Moorside Unit on 19 April 2017. She suffered a heart attack on 30 April 2017 and was pronounced deceased after resuscitation efforts. The principal concerns included gaps in physical observations and clinical review, deficiencies in handover and emergency-response equipment, and junior doctors’ failure to consider ECG machine printout abnormalities during interpretation.

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 consider ECG machine printouts in clinical interpretation and judgment
Wider context from the report
“It is understood that Pennine Acute NHS Trust employed the junior doctors on the Moorside Unit at Tameside General Hospital. During the course of the inquest we heard evidence from ████████ regarding ECGs that he carried out on Barbara Johnson on the 19th April 2017 at the time of her admission to the Moorside Unit. A number of the doctors understandably did not recall carrying out the ECGs but formed the view from the records that the patient was moving at the time that the ECGs were performed. Thus, he explained, had an impact on the ECG although he was not able to explain the precise impact. At the top of 2 of the ECGs there was a printout from the machine which stated (inter alia) “T Wave abnormality”, “Possible anterolateral ischemia” and “abnormal ECG”. ████████ evidence was that regard would not be had to the printout summary at the top of the ECG and that the doctor would interpret the ECG himself. Whilst it was accepted that the printout is no substitute for a doctor’s interpretation, it did give cause for concern that junior doctors employed by the Trust were routinely ignoring the printout. It was of concern that the printout was not being considered and/or was not informing clinical interpretation and judgment. ”
Source location
Barbara Johnson · 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
Administrative lead-employer responsibilities exclude the host hospital’s quality of care, training and day-to-day trainee supervision.

Verbatim wording from the response
“I can advise that whilst the two junior doctors concerned were technically employed by Pennine Acute NHS Trust, who are the administrative lead employer for all junior doctors across Greater Manchester, Cumbria & Lancashire, they were placed at Tameside General Hospital who acted as the Host Trust. The Host Trust is responsible for the quality of care delivered to patients and direct supervision of a trainee on a day-to-day basis. Pennine Acute Trust, as the lead employer, are simply the administrative employer of the junior doctors, having responsibility for HR issues such as pay and sick leave, but are not responsible for the quality of training and care at a Host Trust.”

Source location
2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
Page 1 · response
Published 16 June 2018
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 host hospital is responsible for care quality and trainee supervision and has the power to address the reported concerns.

Verbatim wording from the response
“I can advise that whilst the two junior doctors concerned were technically employed by Pennine Acute NHS Trust, who are the administrative lead employer for all junior doctors across Greater Manchester, Cumbria & Lancashire, they were placed at Tameside General Hospital who acted as the Host Trust. The Host Trust is responsible for the quality of care delivered to patients and direct supervision of a trainee on a day-to-day basis. Pennine Acute Trust, as the lead employer, are simply the administrative employer of the junior doctors, having responsibility for HR issues such as pay and sick leave, but are not responsible for the quality of training and care at a Host Trust.”

Source location
2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
Page 1 · response
Published 16 June 2018
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 administrative lead employer cannot implement changes at the host hospital because it lacks authority over care delivery and supervision.

Verbatim wording from the response
“As such, I would suggest that Trafford General Hospital were responsible for the quality of the care provided to Barbara Johnson, and for the quality of care and direction supervision of the junior doctors. Therefore, Pennine Acute Trust is unable to implement change at Tameside General Hospital and we request that the Regulation 28 Report is amended and addressed to Tameside Hospital, who have the power to take action to address the concerns within your report.”

Source location
2018-0084-Response-by-Northern-Care-Alliance-NHS-Group
Page 1 · response
Published 16 June 2018
Open published response
28 Nov2017
Inner South London
Concerns raised1
1. Uncertainty in Holter interpretations and identification of NSVTs on traces
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 2
1. Action
  Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated completed
2. Action
  Provide regular Holter-interpretation training for cardiomyopathy fellows through multidisciplinary meetings and consultant-supervised clinics.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Multidisciplinary discussion is not required before ICD implantation because urgent cases can be referred directly to an implanting consultant.
  Stated by Guy'S and St Thomas' NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Mr Harold Chapman · 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 Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.

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
Uncertainty in Holter interpretations and identification of NSVTs on traces
Wider context from the report
“(3) There was also a concern in respect of the holter interpretations and the presence or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new introduction and training regime for its specialist clinical fellows in the interpretation of holter readings. ”
Source location
Mr Harold Chapman · 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
Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.

Verbatim wording from the response
“The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.”

Source location
2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
Page 2 · response
Published 12 February 2018
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 regular Holter-interpretation training for cardiomyopathy fellows through multidisciplinary meetings and consultant-supervised clinics.

Verbatim wording from the response
“At RBHT all Holter monitor traces are interpreted and reported by trained electrophysiology technicians. Training for cardiomyopathy subspecialty fellows in Holter monitor interpretation is provided at regular MDT meetings and consultant supervised clinics, in addition to standard training for general cardiology trainees in rhythm interpretation.”

Source location
2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
Page 2 · response
Published 12 February 2018
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
Multidisciplinary discussion is not required before ICD implantation because urgent cases can be referred directly to an implanting consultant.

Verbatim wording from the response
“Abnormal Holter results are regularly discussed at MDT meetings. MDT discussion is not a pre-requisite for ICD implant at RBHT and urgent cases are referred directly to an implanting consultant who will list the patient as appropriate. Where MDT discussion is required (complex patients or those not meeting all criteria) this occurs within 2 weeks. The non-urgent waiting time for ICD implant from time of agreement to implant is of the order of 8-12 weeks. As a result of the PFD notice the inherited cardiac conditions care group are developing a standard operating procedure for notification of potentially significant arrhythmias.”

Source location
2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
Page 2 · response
Published 12 February 2018
Open published response
29 Nov2016
Birmingham and Solihull
Concerns raised1
1. Lack of formal testing of paramedics’ 12-lead ECG interpretation
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 2
1. Action
  Review the paramedic standards of proficiency for possible amendments addressing the concerns raised.
  Stated by Health and Care Professions CouncilStated in progress
2. Action
  Liaise with the College of Paramedics about whether the paramedic standards of proficiency should be amended.
  Stated by Health and Care Professions CouncilStated planned
AI-generated summary

Rex Brook Hall · 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

Rex Brook Hall died at Solihull Hospital on 28 July 2016 after presenting with right arm pain and atrial fibrillation and subsequently suffering a myocardial infarction and cardiac arrest. Paramedic ECGs showed ST elevation, but this was not recognised or reviewed on arrival at hospital. The principal concern was possible deficiencies in paramedic foundation training, including ECG interpretation, recognition of arm pain as an atypical sign of myocardial infarction, and identification of ST elevation.

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 formal testing of paramedics’ 12-lead ECG interpretation
Wider context from the report
“That there may be deficiencies in the foundation training of paramedics: 1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG; 2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction; and 3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012). ”
Source location
Rex Brook Hall · 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
Review the paramedic standards of proficiency for possible amendments addressing the concerns raised.

Verbatim wording from the response
“The SOPs for paramedics set out the knowledge, skills and abilities individuals must meet and maintain to register with us, and practice safely and effectively as a paramedic. These standards have been revised periodically, to ensure they remain relevant to current practice for the paramedic profession. In relation to the specific points regarding the training of the paramedics in question, the SOPs for paramedics include specific reference to the need for paramedics to:”

Source location
Response-by-HCPC
Page 2 · response
Published 19 February 2017
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
Liaise with the College of Paramedics about whether the paramedic standards of proficiency should be amended.

Verbatim wording from the response
“that all individuals are deemed eligible to apply with us for registration. Once registered, all registrants must continue to maintain their adherence to these standards to remain on the register, including showing evidence of their continuing professional development if audited. We are currently undertaking a review of the SOPs and will liaise with the College of Paramedics on the concerns raised in your report to explore whether any amendments should be made in this regard.”

Source location
Response-by-HCPC
Page 3 · response
Published 19 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise the significance of 12-lead ECG readings

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Deficiencies in ECG interpretation

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to correctly interpret 12 lead ECGs

Lack of further ECG training after identified incorrect interpretation

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.15

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to consider ECG machine printouts in clinical interpretation and judgment

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Respondent positions 1

Respondent positions 1

Actions described in response 15

Respondent positions 4

Respondent positions 3