Concerns raised 9 Lack of careline policy, guidance and training for third-party emergencies View source Failure to recontact the EMA when a caller reports deterioration View source Failure to record clinically relevant information in EMA notes View source Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing View source Failure to check and improve the quality of clinical note taking View source Inadequate quality of the call auditing system View source Failure to obtain and pass on key emergency information from careline callers View source Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement View source Failure to obtain or provide basic clinical advice during careline emergency calls View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Derek Thomas Burt · 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
Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.
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. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of careline policy, guidance and training for third-party emergencies
Wider context from the report “2) I also heard from the careline centre manager that Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves. It was good to learn that both careline operators did respond positively to the cry for help from Mrs Burt. I remained concerned, however, that there is no policy or guidance available for operators to cover this type of emergency or life threatening situation and no training has yet been devised to learn from the unusual circumstances that occurred here .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recontact the EMA when a caller reports deterioration
Wider context from the report “In addition, the first careline operator did not call the EMA back when she learned Mr Burt was non responsive and had developed breathing problems . The CSN confirmed to me that if a second call had been made at that point then the call would have been upgraded to category 1 . This would have been at approx 22:50. In other words around the same time the EMA was trying to call Mrs Burt back. The clinical review was allocated at 22:55 and the second 999 call was logged at 23:15 so approximately 20-25 mins had elapsed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinically relevant information in EMA notes
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review .
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing
Wider context from the report “1) I heard evidence from the call centre manager of Appello Careline and the first careline operator that their system had the capability to speak directly to Mrs Burt without her pressing her wrist alarm button as this could have been done via the digital base unit that was in her bedroom. The system can also set up a 3 way conversation or conference call to include any of the emergency services. Indeed the operator told me she has done this in the past if asked to do so by the emergency services or she has suggested it but she did not do so in this case as she took heed from the EMA.
Conversely, I heard from a CSN with South East Coast Ambulance Service (SECAMB) that she did not know careline companies could set up 3 way conference calls for a CSN to speak to the patient or helper directly. She knew that Police and Fire Services used 3 way conference calls using careline systems but not Ambulance Trusts.
This case had moved from the dispatch to the clinical stack and from the timeline of calls supplied it seems 15 calls were made between 22:52 and 23:23 to the landline and mobile numbers supplied but of course, it was impossible for Mrs Burt to answer them.
No one thought to go back through the digital base unit to offer the basic clinical advice that was needed. I am concerned that both Ambulance Trusts generally as well as Careline companies may not be aware of the potential to save lives using available technology.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to check and improve the quality of clinical note taking
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others . Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of the call auditing system
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and pass on key emergency information from careline callers
Wider context from the report “3) I also remain concerned that the first careline operator did not pass on a key piece of information to the EMA, namely that the caller did not have access to a phone . Nor did she ask if the blood was spurting or dribbling . Although, it was relayed that Mrs Burt was bedbound, the EMA would not have realised that Mrs Burt couldn’t get to the phone as it was in another room.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement
Wider context from the report “6) I was told that SECAMB is taking part in a pilot called Tortoise looking at using AI to improve the accuracy of note taking. It was unclear whether a similar scheme is being explored by careline companies or if there is effective liaison between careline companies and ambulance trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Appello Careline Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or provide basic clinical advice during careline emergency calls
Wider context from the report “5) I heard that an EMA can hold a call and speak to a CSN to get basic first aid advice or join the CSN into the call . Given the volume of blood that had already been lost in this case, I am concerned that this opportunity to give clinical advice was lost especially as the call had come in via a careline operator.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce information capture and communication through continuing operator training, call audits, supervision and operational reviews.
Verbatim wording from the response “Concern 3
Appello Careline Limited will continue to reinforce adherence to established procedures through its ongoing training, audit and supervision processes, including the use of call audits and operational review mechanisms to ensure that relevant information is consistently captured and communicated.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update operator training materials to clarify handling of assistance requests concerning people other than the service user.
Verbatim wording from the response “Concern 2
Appello Careline Limited intends to update its operator training materials to clarify that calls may be received where assistance is sought for another person, for example a household member or visitor.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a triage enhancement requiring operators to establish telephone access and explicitly communicate its absence to emergency services.
Verbatim wording from the response “However, Appello Careline Limited has identified an opportunity to strengthen the information provided to emergency services in circumstances where direct telephone contact is not possible. Appello Careline Limited therefore intends to introduce a proportionate enhancement to its triage process.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor relevant call-handling and note-taking technologies and consider their use where they can demonstrably improve outcomes.
Verbatim wording from the response “Concern 6
Appello Careline Limited will continue to monitor developments in relevant technologies, including those relating to call handling and note taking, and will consider their use where they can demonstrably improve outcomes.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing triage processes are considered appropriate for identifying and communicating relevant information to emergency services.
Verbatim wording from the response “Concern 1
Appello Careline Limited’s existing triage processes require operators to gather and communicate relevant information to emergency services. Those processes remain in place and are considered appropriate to ensure that relevant information is identified and communicated to emergency services.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures already require appropriate assistance where someone other than the service user needs help.
Verbatim wording from the response “Concern 2
Appello Careline Limited’s existing procedures already require operators to arrange appropriate assistance based on the information provided, regardless of whether the person in need is the service user. Assistance was arranged in accordance with those procedures in this case.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
Verbatim wording from the response “Concerns 4 and 5
Appello Careline Limited understands that these concerns relate to the ambulance service’s internal processes, including note taking and clinical triage decision-making.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The failure to communicate deterioration was an individual failure to follow established procedures, not a deficiency in those procedures.
Verbatim wording from the response “Concern 3
Appello Careline Limited accepts that, in this case, certain information indicating deterioration in Mr Burt’s condition was not communicated to the” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further procedural change is not considered necessary because established training, audit and supervision processes will continue reinforcing compliance.
Verbatim wording from the response “Concern 3
Appello Careline Limited will continue to reinforce adherence to established procedures through its ongoing training, audit and supervision processes, including the use of call audits and operational review mechanisms to ensure that relevant information is consistently captured and communicated.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine three-way conference calling will not be introduced because operational complexity and variable call scenarios make it disproportionate or ineffective.
Verbatim wording from the response “Concern 1
Following operational and technical review, Appello Careline Limited does not consider that routinely offering three-way (conference) calling would be proportionate or effective, given the operational complexity and variability of call scenarios.” Source location Response from Appello Careline Operations Director
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures, training, auditing and continuous improvement provide a robust framework for managing the identified risks.
Verbatim wording from the response “Appello Careline Limited considers that its existing procedures, supported by ongoing training, audit and continuous improvement processes, provide a robust framework for managing the risks identified in this case.” Source location Response from Appello Careline Operations Director
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations