9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
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Concerns raised 8 Failure to obtain complete medical and medication information from relevant sources View source Early exit from NHS Pathways Module 0 for third-party calls View source Failure to transfer important and accurate medical information to telecare and emergency services View source Lack of a facility for call handlers to pass calls directly to ambulance triage staff View source Lack of automatic flagging of medical and medication-related risks View source Failure of unanswered patient call attempts to trigger clinical review of triage decisions View source Different ambulance-call handling for third-party callers View source Unavailability of responder telephone numbers within the call handling system View source See 5 more concerns
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John Michael WELLS · 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
John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
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 Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain complete medical and medication information from relevant sources
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Early exit from NHS Pathways Module 0 for third-party calls
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important and accurate medical information to telecare and emergency services
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record , which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for call handlers to pass calls directly to ambulance triage staff
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of medical and medication-related risks
Wider context from the report “(3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet.
I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of unanswered patient call attempts to trigger clinical review of triage decisions
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Different ambulance-call handling for third-party callers
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back . Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” 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 Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of responder telephone numbers within the call handling system
Wider context from the report “(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet).
Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not.
The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations