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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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 Association of Ambulance Chief Executives; 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
×
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 Share and discuss the PFD learning with the ambulance service medical directors group.
Verbatim wording from the response “However, within its remit as a membership organisation for UK NHS ambulance services, AACE does share learning from PFDs across the sector. In relation to this specific PFD report, we recognise that the points of concern relate to:” Source location Response from Association of Ambulance Chief Executives
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 Recommend that each ambulance service review local procedures for handling calls from telecare providers and assess three-way calling availability.
Verbatim wording from the response “1. We were unaware, at a national level, of the facility for ambulance services to hold three-way conference calls with careline operators and their users. We do consider that the use of this function would be extremely helpful in certain circumstances where there is any ambiguity as to the acuity of the clinical condition of the user / person needing assistance. AACE has shared and discussed this PFD with the ambulance service medical directors group (NASMeD) and have recommended that each ambulance service reviews their own local procedures into handling calls from telecare providers and to establish if their three-way calling is available.” Source location Response from Association of Ambulance Chief Executives
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 Responsibility for continuing telecare decision-support-tool work was transferred to NHS England's stewardship.
Verbatim wording from the response “Following liaison with NHS England, it was agreed that this work would continue under their stewardship. In 2023 the TSA published their Decision Support Tool Guidance, and a TEC Call Handling Support Tool.” Source location Response from Association of Ambulance Chief Executives
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 specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Verbatim wording from the response “With respect to the matters of concern in relation to the care of Derek Burt, AACE is not in a position to respond; the specific details relate to and should subsequently be addressed by both Appello and SECAMB.” Source location Response from Association of Ambulance Chief Executives
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 organisation cannot offer a view on guidance for careline operators handling assistance calls made on behalf of another person.
Verbatim wording from the response “3. This specific issue is not one AACE is able to offer a view upon.” Source location Response from Association of Ambulance Chief Executives
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 organisation and its members cannot provide the clinical governance needed for a telecare decision-support tool.
Verbatim wording from the response “The critical element of our work with them relates to the development of a decision-support tool. TSA did not have the appropriate level of clinical governance to support this, and AACE and its members are not in a position to offer this.” Source location Response from Association of Ambulance Chief Executives
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 organisation cannot mandate or instruct ambulance services, whose local procedures and implementation decisions remain their responsibility.
Verbatim wording from the response “AACE is a private company owned by the English and Welsh Ambulance NHS trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and assists with the implementation of nationally agreed policies and guidance. It is a membership organisation representing all UK NHS ambulance services and our primary focus is the ongoing development of ambulance service provision and the improvement of patient care. AACE possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services; however, it has national influence via the regular meetings of ambulance chief executives and chairs, along with a network of national specialist groups.” Source location Response from Association of Ambulance Chief Executives
Open published response
Concerns raised 6 Insufficient clarity and usability of vascular emergencies guidance View source Lack of clinical interpretation and action guidance for aortic dissection risk scores View source Confusing classification of aortic aneurysm and dissection guidance View source Failure to recognise and urgently manage suspected aortic dissection View source Unclear interpretation of blood pressure in suspected aortic dissection View source Inadequate analysis and organisational learning from clinical incidents View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JOHN SOUTHAM KEEN · 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 Southam Keen, who had a known ascending aortic aneurysm, developed sudden chest pain radiating to his back and neck at home on 19 August 2023. Paramedics recorded the aneurysm incorrectly as abdominal and took him to a local acute hospital rather than directly to a specialist arterial centre; after a delay, he suffered cardiac arrest before surgery, sustained a fatal hypoxic brain injury and died on 24 August 2023. The report raises concerns about the paramedics’ assessment, SWAST NHS’s inadequate incident review, and confusing and unclear ambulance guidance on suspected aortic dissection.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and usability of vascular emergencies guidance
Wider context from the report “JRCALC
1)
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others . Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical interpretation and action guidance for aortic dissection risk scores
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk . This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Confusing classification of aortic aneurysm and dissection guidance
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm , which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and urgently manage suspected aortic dissection
Wider context from the report “1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS, with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.
All clinical witnesses that gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection . Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer . If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred. The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset rad iating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation .
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians, and do not take steps to try and learn from these incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unclear interpretation of blood pressure in suspected aortic dissection
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning , or how the issue of a patient’s blood pressure may be relevant to overall clinical risk .
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Inadequate analysis and organisational learning from clinical incidents
Wider context from the report “1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS , with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.
All clinical witnesses that gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection. Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer. If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred. The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset rad iating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation.
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians , and do not take steps to try and learn from these incidents when they occur , then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
” 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 Amend hypotension wording to clarify the relevance of high and low blood pressure.
Verbatim wording from the response “3. Hypotension as a risk factor” Source location Response from Association of Ambulance Chief Executives
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 Review aortic aneurysm and dissection guidance with paramedic input to improve usability.
Verbatim wording from the response “Your matter of concern was brought to the attention of JRCALC, and specifically to the clinical leads for the vascular emergencies guideline. These clinical leads are our expert advisors who have a background in vascular and surgical knowledge and have offered to support this work. They are currently reviewing the sections of guidance that relate to aortic aneurysms and aortic dissections. As part of this process of review, we will ensure paramedic input to the guidance is as user friendly as possible. We had an initial meeting on the 22 June 2026 to discuss your concerns which I have summarised below.” Source location Response from Association of Ambulance Chief Executives
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 Fully revise and update the aortic aneurysms section to remove confusion and improve clarity.
Verbatim wording from the response “1. Section titled ‘aortic aneurysms’” Source location Response from Association of Ambulance Chief Executives
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 hospital-validated risk score would lead to actions unavailable in pre-hospital care, such as D-Dimer testing.
Verbatim wording from the response “The detection risk score table was included in a revision of the guideline in 2024. We aimed to assist in identifying the more subtle signs of vascular emergencies that may be missed. As this clinical risk stratification tool is not specifically designed for pre-hospital use, and only validated for hospital assessment, calculating a risk score would lead to actions that cannot be undertaken in the pre-hospital setting, for example D-Dimer testing. The tool was modified so that if any score was positive in any column, it was recommended that the patient should be conveyed to hospital. We recognise this information may be improved with updated formatting of the table.” Source location Response from Association of Ambulance Chief Executives
Open published response
16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source See 2 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
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” 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 Support development and dissemination of defibrillator-related guidance with the Resuscitation Council UK.
Verbatim wording from the response “AACE has also worked alongside RCUK to support the development and dissemination of related guidance, an example being RCUK’s current delivery of field of play guidance, specifically focused at grassroots sports.” Source location Response from Association of Ambulance Chief Executives
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 Collaborate with partners to deliver and disseminate public communications about defibrillator use.
Verbatim wording from the response “AACE has supported a number of nationwide initiatives to improve access to defibrillators. We co-produced a consensus statement in 2024 recommending that all defibrillators are stored in unlocked boxes and available 24/7. In conjunction with ambulance services, AACE regularly collaborates with partners to deliver and disseminate public-facing communications about the use of defibrillators. There is ongoing work to improve the placement of defibrillators through strategic optimisation tools, to identify areas of highest risk, and lowest access to defibrillators.” Source location Response from Association of Ambulance Chief Executives
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 Support national initiatives that increase cardiac-arrest recognition, CPR education and first-aid training.
Verbatim wording from the response “We fully support other national initiatives and there are a wealth of national programmes seeking to increase recognition of cardiac arrest, early CPR and defibrillation use. Ambulance services are active in delivering such training to the public. AACE’s out-of-hospital cardiac arrest programme is key in supporting such initiatives including mandating CPR training in schools and the introduction of first aid training for driving tests. We also support Restart a Heart (RSAH) and RSAH Live: annual initiatives led by Resuscitation Council UK (RCUK) and Save a Life Scotland which aim to increase the number of people surviving out-of-hospital cardiac arrests by improving cardiac arrest awareness and CPR education.” Source location Response from Association of Ambulance Chief Executives
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 Encourage and support Community First Responders across the ambulance sector to provide early CPR and defibrillation.
Verbatim wording from the response “Bystander CPR rates across the English ambulance services continues to be high (>75%) and defibrillator use is improving with the highest recorded use to date in 2024 (2025 data not yet available). To support timely access to CPR and defibrillators, we encourage and support the use of Community First Responders (CFRs) across the ambulance sector. These volunteers are trained in CPR and carry with them defibrillators and respond to 999 calls including cardiac arrests. Often, they can be tasked and arrive before the ambulance and can help in the early recognition of cardiac arrest” Source location Response from Association of Ambulance Chief Executives
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 Restart a Heart and related public cardiac-arrest awareness and CPR-education initiatives.
Verbatim wording from the response “We fully support other national initiatives and there are a wealth of national programmes seeking to increase recognition of cardiac arrest, early CPR and defibrillation use. Ambulance services are active in delivering such training to the public. AACE’s out-of-hospital cardiac arrest programme is key in supporting such initiatives including mandating CPR training in schools and the introduction of first aid training for driving tests. We also support Restart a Heart (RSAH) and RSAH Live: annual initiatives led by Resuscitation Council UK (RCUK) and Save a Life Scotland which aim to increase the number of people surviving out-of-hospital cardiac arrests by improving cardiac arrest awareness and CPR education.” Source location Response from Association of Ambulance Chief Executives
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 Training and education of ambulance staff and the public, including defibrillator use, are outside the organisation’s responsibilities.
Verbatim wording from the response “We must emphasise that as a membership organisation, AACE is not responsible for the training or education of ambulance staff, or the public / lay people. We do, however, believe it is everyone’s responsibility to consider the need for first aid training and how to recognise and help someone in cardiac arrest by being able to perform cardio-pulmonary resuscitation (CPR) and use a defibrillator if available, until professional help arrives.” Source location Response from Association of Ambulance Chief Executives
Open published response
2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
View report summary
Concerns raised 7 Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital View source Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint View source Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage View source Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint View source Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables View source Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials View source Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status View source See 4 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
Scott Darren TAYLOR · 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
Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital
Wider context from the report “b. Whilst it would not have changed the outcome for Mr Taylor, arm and leg restraints were not removed by police officers in this case when it was understood that Mr Taylor was unconscious and when Mr Taylor was being conveyed to hospital . Police officers who gave evidence were not clear that this was a requirement of the policy .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Wider context from the report “b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients . Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active restraint.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Wider context from the report “a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint
Wider context from the report “a. It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1 . This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables
Wider context from the report “a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance . Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials
Wider context from the report “d. The EEAST documents continue to use the term ‘Excited Delirium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status
Wider context from the report “c. The EEAST updated training on Acute Behavioural Disturbance, active restraint and reports received from police and correct coding remains confusing with the policy and training handouts in December 2023 with discrepancies between those who are sectioned and those who are not. Persons confirmed with Acute Behavioural disturbance and in active police restraint being coded as Category 2 and those in the same circumstances and ‘sectioned’ will require a Category 1 response . The difference appears to be one related to the Mental Health Act and not the presentation or clinical requirements of the person .
” 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 Develop, revise and publish clinical practice guidance for recognising, assessing and managing suspected acute behavioural disturbance, including safe restraint and urgent transfer.
Verbatim wording from the response “With regard to the ABD, over a number of years we have developed and further revised UK ambulance service clinical practice guidelines for clinicians. This has been based on learning from ABD cases we have been involved with, some of these via coroners’ inquests and preventing future death reports. We have published guidance for patients that are agitated, have delirium and have suspected ABD. This is to ensure that the recognition, assessment and management of these patient presentations are considered by ambulance clinicians. We emphasise in the ABD guidance that the condition is a clinical emergency and that the patient may suffer sudden cardiovascular collapse or cardiac arrest or both with little or no warning.” Source location Response from Association of Ambulance Chief Executives
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 National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.
Verbatim wording from the response “With regard to the required classification for ambulance response to emergencies, AACE do not set the categories nationally of ambulance response. Ambulance call codes are determined by NHS England by the Emergency Call Prioritisation Advisory Group (ECPAG). We are aware that cases of suspected ABD should be assigned a Category 2 response, which is the immediate dispatch of an emergency ambulance. However, ambulance services are advised that a senior clinician within the” Source location Response from Association of Ambulance Chief Executives
Open published response
Concerns raised 2 Lack of mandatory and comprehensive paramedic training in obstetric emergencies View source Failure to adhere to clinical guidance for assessing and managing delayed breech birth View source
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
Mohammed Ismail KHAN · 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
Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development .
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course .
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted .
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course.
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.
” 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 and enhance the JRCALC breech-birth guideline using evidence review, expert consensus, paramedic usability testing, images and instructional videos.
Verbatim wording from the response “The JRCALC guidelines contain guidance on the assessment and management of maternal emergencies, and we have a specific guideline for breech birth. The guideline was updated in September 2023 following extensive review by obstetricians, midwives, and paramedics. During the ████████” Source location Response from Association of Ambulance Chief Executives
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 Responsibility for paramedic training and education falls outside AACE’s remit.
Verbatim wording from the response “With regard to your matter of concern around the training and education of paramedics, AACE are not responsible for this. However, we have shared the report via our networks and specifically with the national education network for ambulance trusts (NENAS), with the national pre-hospital maternity and newborn care group and the national ambulance services medical directors’ group (NASMeD) for them to consider your matters of concern in their own organisations.” Source location Response from Association of Ambulance Chief Executives
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 Training concerns were shared with ambulance education and clinical networks for consideration by their organisations.
Verbatim wording from the response “With regard to your matter of concern around the training and education of paramedics, AACE are not responsible for this. However, we have shared the report via our networks and specifically with the national education network for ambulance trusts (NENAS), with the national pre-hospital maternity and newborn care group and the national ambulance services medical directors’ group (NASMeD) for them to consider your matters of concern in their own organisations.” Source location Response from Association of Ambulance Chief Executives
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 Qualified paramedic maternity training is the responsibility of individual ambulance trusts.
Verbatim wording from the response “With regard to under-graduate and post-graduate paramedic training we are aware of variation in the provision of training for paramedics in maternity care and breech birth in both Universities (accredited by the HCPC) and ambulance services which for qualified paramedics is the responsibility of individual ambulance trusts. Additionally, we do not have any control over the allocation of specific funding for maternity training. We are aware that some training is delivered face-to-face to staff, often supplemented by online modules, webinars, and instructional videos. Simulation and hands on practice are widely used with training covers both theoretical and practical skills. Refresher training varies with some services offering training every 1-4 years, annually or as a part of continuous professional development.” Source location Response from Association of Ambulance Chief Executives
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 AACE has no control over allocating specific funding for maternity training.
Verbatim wording from the response “With regard to under-graduate and post-graduate paramedic training we are aware of variation in the provision of training for paramedics in maternity care and breech birth in both Universities (accredited by the HCPC) and ambulance services which for qualified paramedics is the responsibility of individual ambulance trusts. Additionally, we do not have any control over the allocation of specific funding for maternity training. We are aware that some training is delivered face-to-face to staff, often supplemented by online modules, webinars, and instructional videos. Simulation and hands on practice are widely used with training covers both theoretical and practical skills. Refresher training varies with some services offering training every 1-4 years, annually or as a part of continuous professional development.” Source location Response from Association of Ambulance Chief Executives
Open published response
7 Jul 2025 David Gifford · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of JRCALC guidelines to provide guidance on atypical vascular emergency presentations View source Lack of ambulance training and knowledge on subtle signs of vascular emergencies View source
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
David Gifford · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Gifford died at Southmead Hospital on 26 November 2024 after an acute ruptured abdominal aortic aneurysm associated with a fractured stent and endoleak. In the weeks before his death, he had multiple GP visits and made two 999 calls about pain before being conveyed to hospital. The report raised concerns that ambulance training and guidance may not sufficiently address subtle or non-classic signs of vascular emergencies, particularly in people with an extensive aortic history.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of JRCALC guidelines to provide guidance on atypical vascular emergency presentations
Wider context from the report “(1) Training and knowledge focuses on the classic signs and symptoms associated with an AAA. However, there are a group of patients who will not present in this way, and who may be challenging to diagnose. Whilst there may be many medical conditions that could be similar, there does not seem to be much focus given to the identification of vascular emergencies within training and knowledge updates. Therefore when paramedics attend emergencies, in the absence of classic symptoms, they may be wrongly reassured. Where a person has an extensive aortic history, the importance of aortic pathology should be considered.
(2) There has not been training or medical education for ambulance on vascular emergencies for a long time. The evidence was that JRCALC guidelines did recently highlight the number of patients that may not present with the traditional ‘red flags’ but did not provide further guidance . This is a national issue where ambulance staff should be knowledgeable about the more subtle signs of vascular emergencies that may be missed.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance training and knowledge on subtle signs of vascular emergencies
Wider context from the report “(1) Training and knowledge focuses on the classic signs and symptoms associated with an AAA. However, there are a group of patients who will not present in this way, and who may be challenging to diagnose. Whilst there may be many medical conditions that could be similar, there does not seem to be much focus given to the identification of vascular emergencies within training and knowledge updates . Therefore when paramedics attend emergencies, in the absence of classic symptoms, they may be wrongly reassured. Where a person has an extensive aortic history, the importance of aortic pathology should be considered.
(2) There has not been training or medical education for ambulance on vascular emergencies for a long time . The evidence was that JRCALC guidelines did recently highlight the number of patients that may not present with the traditional ‘red flags’ but did not provide further guidance. This is a national issue where ambulance staff should be knowledgeable about the more subtle signs of vascular emergencies that may be missed .
” 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 abdominal pain and vascular emergency guidelines, considering terminology on atypical aortic presentations, the aortic dissection risk score and endoleaks after repair.
Verbatim wording from the response “We discussed your matters of concerns at our JRCALC meeting on the 22 July 2025. JRCALC consists of expert medical advisors including those with vascular and surgical knowledge. The committee made the decision to undertake a review of the existing abdominal pain and vascular emergencies guidelines. We will look to include additional terminology for clinicians to ensure that they take account of the potential for patients with extensive aortic history not to present with traditional red flag symptoms and to carefully consider whether they should be transported to hospital. We will also advocate the use of the Aortic Dissection Detection risk score during their clinical assessment to aid decision-making around conveyance. Finally, we will also include reference to the potential for ‘Endoleaks’ following an aortic repair.” Source location Response from Association of Ambulance Chief Executives
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 Training and education of ambulance staff are outside the respondent’s responsibility.
Verbatim wording from the response “AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors (NASMeD) at our next national meeting. We will” Source location Response from Association of Ambulance Chief Executives
Open published response
24 Oct 2024 Aran Sean BRADBURY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Aran Sean BRADBURY · 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 21 August 2023, Aran Sean Bradbury applied a ligature to his neck, suffered cardiac arrest and was taken to hospital, where he died on 25 August 2023 from hypoxic ischaemic brain injury following hanging. The report raised concern that ambulance triage coding may assign Category 3 rather than Category 2 priority to patients with a history of mental illness who have ingested substances, potentially resulting in a longer wait for an ambulance. In this case, there was a two-hour delay between the 999 call and ambulance dispatch.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code
Wider context from the report “4) I heard oral evidence that: 25-C codes refer to patients with altered levels of consciousness; Code 25-C-1 (which results to a Category 3 prioritisation) refers to patients with an altered level of consciousness and a history of mental illness; Other subsets of Code 25-C exist, including 25-C-2 which refers to patients with an altered level of consciousness who have ingested substances; and that Code 25-C-2 would result to a Category 2 prioritisation.
5) The evidence I heard was that although Mr Bradbury had ingested substances which might have resulted in a 25-C-2 coding (and therefore at Category 2 prioritisation for an ambulance), given that he also had a history of mental illness he was coded as 25-C-1 (and therefore a Category 3 priority) because the system does not allow for consideration of Codes 25-C-2, 25-C-3 etc if it had determined a 25-C-1 code based on the information provided .
6) The operation of this system as described in the evidence I heard could result in patients who might otherwise warrant a category 2 prioritisation being prioritised as Category 3 and therefore wait longer for an ambulance to attend . Patients with a history of mental illness would appear to fall within this group.
” Open source report
13 Aug 2024 Margaret HUNTLEY · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 7 Insufficient awareness of Steroid Emergency Cards View source Insufficient usage of Steroid Emergency Cards View source Lack of Ambulance Service staff understanding of steroid medication importance and required actions View source Failure of GPs to routinely request Ambulance Service health-condition alerts View source Lack of triage guidance for responding when patients report prescribed steroid medication View source Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts View source Lack of triage guidance for establishing detailed steroid prescription information View source See 4 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
Margaret HUNTLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.
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× 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage, and awareness, of Steroid Emergency Cards .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient usage of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage , and awareness, of Steroid Emergency Cards .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of Ambulance Service staff understanding of steroid medication importance and required actions
Wider context from the report “1. There is a lack of understanding amongst (non-clinical and clinical) Ambulance Service staff as to the importance of steroid medication and the steps to be taken should a patient (a) report that they are prescribed steroid medication and/or (b) present with symptoms potentially consistent with steroid insufficiency/Addison’s Crisis.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to routinely request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s; (b) this action is not routinely being taken by GPs .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for responding when patients report prescribed steroid medication
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s ; (b) this action is not routinely being taken by GPs.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for establishing detailed steroid prescription information
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it ; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication.
” 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 Include an image of the NHS steroid emergency card in JRCALC steroid-dependent patient guidance to raise awareness among ambulance clinicians.
Verbatim wording from the response “Within our JRCALC guidance for steroid-dependent patients, we have an image of the NHS steroid emergency card. We included this particularly to help raise awareness amongst ambulance clinicians. In addition ambulance clinicians can often gain access to the patients’ health care record where clinical information such as steroid dependency may be available.” Source location Response from Association of Ambulance Chief Executives
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 Education and training of ambulance paramedics is outside the respondent’s remit.
Verbatim wording from the response “Firstly, it is important to note that the education and training of paramedics is not within the remit of AACE or JRCALC.” Source location Response from Association of Ambulance Chief Executives
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 NHS ambulance services are responsible for processing 999 calls through approved triage systems.
Verbatim wording from the response “AACE are not responsible for the guidance or processes for ambulance staff triaging calls. NHS Ambulance Services are required to process 999 calls through an approved triage system and there are currently two different systems in use in ambulance trusts. We know that these systems are able to advise patients to take their emergency supply of steroids.” Source location Response from Association of Ambulance Chief Executives
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 respondent is not responsible for guidance or processes used to triage ambulance calls.
Verbatim wording from the response “AACE are not responsible for the guidance or processes for ambulance staff triaging calls. NHS Ambulance Services are required to process 999 calls through an approved triage system and there are currently two different systems in use in ambulance trusts. We know that these systems are able to advise patients to take their emergency supply of steroids.” Source location Response from Association of Ambulance Chief Executives
Open published response
7 Jun 2024 Fern Elisabeth Foster · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 2 Lack of ambulance carriage of appropriate antidote medication for on-scene administration View source Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment View source
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
Fern Elisabeth Foster · 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
Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.
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× 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance carriage of appropriate antidote medication for on-scene administration
Wider context from the report “(2) The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue) , whilst trialled elsewhere, is not part of regional or national protocol . Swift access to this in circumstances where ████████ is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment
Wider context from the report “(1) The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of ████████ (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene , which may provide the only likely means of prevention of death where sufficient quantity has been ingested.
” 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 Update JRCALC overdose and poisoning guidance to cover sodium nitrate/nitrite poisoning, TOXBASE and NPIS advice, oxygen administration, and rapid conveyance to hospital.
Verbatim wording from the response “We are currently reviewing and updating our overdose and poisoning JRCALC guidance for paramedics, and we will be including sodium nitrate/nitrite poisoning as an example of a chemical that can be ingested. The guidance will recommend that paramedics consult the National Poisons Information Service (NPIS) database (TOXBASE) and where necessary use the NPIS 24-hour, seven-day telephone advice line for details of the effects of specific substances and advice around possible toxic doses. Where a potentially or immediately life threatening substance has been taken, rapid conveyance to hospital will be recommended.” Source location Response from AACE
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 Individual ambulance trusts, authorised by their medical directors, decide which drugs their services carry.
Verbatim wording from the response “Firstly, it must be noted that neither AACE or NASMeD has the authority to mandate the carriage of any specific drugs, including antidotes, by NHS Ambulance Services. The decision as to which drugs each ambulance service carries is made by that individual NHS ambulance Trust, authorised by the Medical Director.” Source location Response from AACE
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 Ambulance attendance triage and prioritisation are outside AACE and NASMeD’s remit.
Verbatim wording from the response “The process for triaging and prioritising ambulance attendance is not within the remit of AACE or NASMeD. The categorisation of 999 calls is overseen at a national level through the NHS England clinical coding group which reports to Emergency Call Priority Advisory Group (ECPAG). The algorithms for NHS” Source location Response from AACE
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 ambulance carriage, training and JRCALC inclusion of methylene blue are not considered appropriate because evidence is currently insufficient.
Verbatim wording from the response “We have considered whether to recommend that ambulance services carry a specific antidote to sodium nitrate/nitrite poisoning such as methylene blue, and whether to include this in our JRCALC guidance. We have liaised with a number of our partners and have come to a decision that it is not appropriate to recommend that all ambulance services should be trained in its use or included in our JRCALC guidance.” Source location Response from AACE
Open published response
6 Feb 2024 O’Shea Medad Dover · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Failure of national JRCALC guidance to address conveyance to an obstetrics unit when delivery is not progressing View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
O’Shea Medad Dover · 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
O’Shea Medad Dover was delivered after a delayed ambulance response to the mother’s emergency call and was subsequently found to have no foetal heart rate. Resuscitation restored circulation, but the inquest narrative stated that O’Shea was likely subjected to acute severe hypoxia and would likely have survived if the call had been correctly categorised and hospital treatment had occurred earlier. The substantive concern was whether national JRCALC guidance should include advice to convey patients to an obstetrics unit when delivery is not progressing.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of national JRCALC guidance to address conveyance to an obstetrics unit when delivery is not progressing
Wider context from the report “1. Consideration to be given for the national JRCALC guidance to include the London Ambulance Service’s JRCALC Plus recommendation that where delivery is not progressing the patient should be conveyed to an obstetrics unit ;
” 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 the guidance after review and issue the revised content as a clinical update through the App following required approvals.
Verbatim wording from the response “The guidance will be updated following the review we have commenced, and this is expected to take around three months. When the guidance is updated it will be issued as a clinical update onto the App following our usual process which involves approvals from JRCALC and our National Ambulance Medical Directors group (NASMeD).” Source location Response from Association of Amblance
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 Review two maternal-care guidelines to address conveying patients when delivery is not progressing, consulting obstetric, midwifery and national maternity experts.
Verbatim wording from the response “We are consulting with our expert advisors for our JRCALC guidance, obstetricians and midwives and the NHS England National Maternity team.” Source location Response from Association of Amblance
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 decision whether to convey a patient would remain with attending clinicians because individual circumstances may differ.
Verbatim wording from the response “As a result of the learning from this incident two guidelines are now under review and will take into account the matters of concern you have raised about conveying the patient if delivery is not progressing. The decision whether to move the patient may differ in every individual situation and would continue to be made by the attending clinicians.” Source location Response from Association of Amblance
Open published response
8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Failure of ambulance investigations to compare attendances and identify learning View source Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma View source Failure to assess, audit and plan for disruption to children’s asthma service access View source Under-resourcing of the asthma and allergy children’s service View source Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma View source Failure of ambulance investigations to identify omitted emergency treatments and access View source Failure to incorporate investigation learning into training and alerts View source Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management View source Failure to involve children directly in asthma service consultations View source Limited availability of trained paediatric endotracheal intubation capability View source Non-mandatory asthma training for health professionals caring for children and young people View source See 8 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
WILLIAM BRIAN KIN GRAY · 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 had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to compare attendances and identify learning
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand :
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, audit and plan for disruption to children’s asthma service access
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances . There was no risk assessment of the impact on the Service , and no audit of whether this was sufficient to manage the Service . There is no contingency plan in place should this issue arise again .
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the asthma and allergy children’s service
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand .
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma
Wider context from the report “(1) Experienced hospital paediatric doctors all gave evidence that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma . The beneficial effects of the administration adrenalin was not considered , William’s presentation on arrival at hospital was falsely reassuring.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to identify omitted emergency treatments and access
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate investigation learning into training and alerts
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated .
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to involve children directly in asthma service consultations
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Limited availability of trained paediatric endotracheal intubation capability
Wider context from the report “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedics skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew:
i. The Trust treatment for those aged 12 and over permits endotracheal intubation by those ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on HEMS arriving in sufficient time if the airway cannot be sufficiently managed.
ii. Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation
iii. there is a difference in provision of life-saving treatment in Essex between those over 12 and for children under 12 and HEMS is a charity with very limited resource across a very large county .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory asthma training for health professionals caring for children and young people
Wider context from the report “(5) Training for health professionals who care for children and young people is not mandatory
The National Capabilities Framework for Professionals who care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory
” 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 asthma guideline and assess whether its severity assessment and management algorithm require clearer detail or greater emphasis on adrenaline.
Verbatim wording from the response “At the JRCALC committee meeting on 9th January 2024 we discussed this preventing future deaths report as an agenda item. A decision was made to undertake a review of the guideline and particularly the assessment and management algorithm and decide if it can be made clearer and have more detail and emphasis on the use of adrenaline.” Source location Response from Association of Ambulance Chief Executives
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 Review JRCALC guidance against the concerns raised about asthma and airway management.
Verbatim wording from the response “In summary, we have reviewed our JRCALC guidance in relation to the matters of concern you have raised and will now review the asthma guideline and make changes if these are deemed to be required. We will also share the details of your concerns with our national ambulance service medical directors’ group (NASMeD). They have regular meetings where learning from incidents and preventing future death reports are discussed. We will suggest that medical directors of the UK ambulance services consider if they believe any further education or awareness is needed for their clinicians, in relation to airway management and asthma and particularly in relation to considering administering adrenaline in asthma.” Source location Response from Association of Ambulance Chief Executives
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 Mandating regular airway training and practice is beyond JRCALC’s scope.
Verbatim wording from the response “With regard to airway management, the JRCALC guidelines provide guidance in the resuscitation sections on managing an airway and using a stepwise approach including considering when to progress from one airway technique to another. As you will be aware, airway management is a practical skill and needs regular training and practice which is beyond the scope of JRCALC to mandate. It is for the individual clinicians and the organisation that they work for to ensure the competency of airway skills and agree which advanced airway skills and airway adjuncts should be used. In managing a difficult airway such as in the case of life threatening or near fatal asthma, part of the training of a paramedic would be to understand the potential difficulties that may be encountered and the strategies that may need to be considered in each individual case.” Source location Response from Association of Ambulance Chief Executives
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 AACE is not constituted to mandate or instruct ambulance services on responsive safety measures.
Verbatim wording from the response “It may be helpful for us to explain that AACE is a private company owned by the English and Welsh NHS ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the implementation of national agreed policy and to act as an interface, where appropriate at a national level, between them and their stakeholders. It is a company owned by NHS organisations and possesses the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance chief executives and chairs along with a network of national specialist sub-groups.” Source location Response from Association of Ambulance Chief Executives
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 Individual clinicians and employing organisations must ensure airway competency and determine advanced airway skills and adjuncts used.
Verbatim wording from the response “With regard to airway management, the JRCALC guidelines provide guidance in the resuscitation sections on managing an airway and using a stepwise approach including considering when to progress from one airway technique to another. As you will be aware, airway management is a practical skill and needs regular training and practice which is beyond the scope of JRCALC to mandate. It is for the individual clinicians and the organisation that they work for to ensure the competency of airway skills and agree which advanced airway skills and airway adjuncts should be used. In managing a difficult airway such as in the case of life threatening or near fatal asthma, part of the training of a paramedic would be to understand the potential difficulties that may be encountered and the strategies that may need to be considered in each individual case.” Source location Response from Association of Ambulance Chief Executives
Open published response
7 Nov 2023 Michael John VINCENT · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Long lie after a fall in elderly people View source Failure to provide allocated ambulance responses within the expected response time View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael John VINCENT · 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
Michael John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Long lie after a fall in elderly people
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death . Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to provide allocated ambulance responses within the expected response time
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay , during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin . There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience . Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” Open source report
Concerns raised 2 Lack of guidance or protocols on when to take patients to hospital for thrombolysis View source Lack of guidance or protocols on when to stop resuscitation View source
Responses linked to these concerns
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AI-generated summary
Mark Bennett · 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
Mark Bennett died at Meadowhall Shopping Centre Sheffield on 14 April 2022 from a pulmonary embolism following a leg injury and immobility after a trip in the London Underground. During the inquest, concerns were raised that ambulance guidance was unclear about how long resuscitation should continue and when patients should be taken to hospital for possible thrombolysis, and that this might place future patients at risk.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or protocols on when to take patients to hospital for thrombolysis
Wider context from the report “5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or protocols on when to stop resuscitation
Wider context from the report “5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis.
” 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 Participate in the ongoing national study examining how and where to stop out-of-hospital cardiac-arrest resuscitation attempts.
Verbatim wording from the response “We are supportive and engaged with a current and ongoing National Institute for Health Research funded study titled: Exploring and improving resuscitation decisions in out of hospital cardiac arrest. The study aims to determine what is the best approach for deciding when and where to stop resuscitation attempts. Presentation of research findings to a stakeholder group took place on 18th October 23 of which a number of AACE representatives attended. The output from this research will be an evidence informed, ethically grounded, termination of resuscitation guideline, which is acceptable to NHS staff, patients and their relatives. Subject to relevant approval processes, we anticipate that the results of this study may lead to an update to our JRCALC guidance leading to better decisions for patients and their relatives.” Source location Response from Association of Ambulance Chief Executives
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 Continue reviewing and updating ambulance clinical guidance regularly and when new evidence becomes available.
Verbatim wording from the response “The JRCALC guidelines are produced to assist UK Paramedics undertake their role effectively. We appreciate that our clinicians have to make difficult decisions around resuscitation practice, especially in relation to when to commence and when to terminate resuscitation. Many factors need to be taken into account, often rapidly and during stressful situations. We are continually reviewing and updating all our guidance on a regular basis and when new evidence becomes available.” Source location Response from Association of Ambulance Chief Executives
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 termination-of-resuscitation guidance, extending the recommended termination decision point from 20 to 30 minutes.
Verbatim wording from the response “With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes.” Source location Response from Association of Ambulance Chief Executives
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 JRCALC guidance provides resuscitation, termination, thrombolysis and conveyance instructions for ambulance clinicians.
Verbatim wording from the response “With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes.” Source location Response from Association of Ambulance Chief Executives
Open published response
15 Aug 2023 Leonard Jomo Isaac KING · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to recognise epiglottitis in adults View source
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
Leonard Jomo Isaac KING · 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
Leonard Jomo Isaac King died at Milton Keynes University Hospital on 4 May 2022 following a hypoxic cardiac arrest caused by airway obstruction from epiglottitis. The report identified concerns that adult epiglottitis may be mistaken for a sore throat or tonsillitis, and that there were missed opportunities to recognise and escalate his condition and transfer him to an emergency department.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise epiglottitis in adults
Wider context from the report “Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis. It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis .
The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring . Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Prompt recognition and treatment is lifesaving.
” 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 Develop new ambulance guidance that covers adult epiglottitis, key assessment and management points, and rapid conveyance for lifesaving treatment.
Verbatim wording from the response “With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. We currently have guidance for children with suspected epiglottitis but not for adults. We had already started to scope and develop new guidance for ambulance clinicians on rarer and specific conditions that need pre-hospital clinical assessment and management that differs from standard practice. We appreciate the importance of the prompt recognition or suspicion of suspected epiglottitis in adults and that typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice.” Source location Response from Association of Ambulance Chief Executives
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 Training and education of ambulance staff are outside the respondent’s responsibility.
Verbatim wording from the response “AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors at our next meeting. We will suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required. We will also share the report with education leads of ambulance trusts, via the national education network for ambulance trusts.” Source location Response from Association of Ambulance Chief Executives
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 Individual ambulance services are responsible for considering whether adult epiglottitis education or awareness-raising is required.
Verbatim wording from the response “AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors at our next meeting. We will suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required. We will also share the report with education leads of ambulance trusts, via the national education network for ambulance trusts.” Source location Response from Association of Ambulance Chief Executives
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” Open source report
19 Apr 2023 DAVID ERNEST MASON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents View source See 5 more concerns
Responses linked to these concerns
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AI-generated summary
DAVID ERNEST MASON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress . Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that , as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy , to prevent the development of an acute adrenal crisis.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” 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 Revise JRCALC guidance to emphasize steroid administration after trauma or physiological stress.
Verbatim wording from the response “Your first matter of concern relates to our ‘JRCALC guidance’ not being sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. The JRCALC guidelines have been in existence since the 1990’s but it was only in 2022 that we decided that a standalone guideline for steroid dependent patients was needed. We have decided that the wording and emphasis on administering steroids to patients who suffer trauma or physiological stress could have more emphasis placed on it, so we are now in the process of revising our guidance.” Source location Response from Association of Ambulance
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 Develop steroid-dependent patient guidance with input from patient representatives and clinical advisers.
Verbatim wording from the response “Your first matter of concern relates to our ‘JRCALC guidance’ not being sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. The JRCALC guidelines have been in existence since the 1990’s but it was only in 2022 that we decided that a standalone guideline for steroid dependent patients was needed. We have decided that the wording and emphasis on administering steroids to patients who suffer trauma or physiological stress could have more emphasis placed on it, so we are now in the process of revising our guidance.” Source location Response from Association of Ambulance
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 AACE has no responsibility for changing the NHS Pathways system used to assess 999 calls in the West Midlands.
Verbatim wording from the response “With regard to your second matter of concern about the advice given in ambulance control centres to people who call 999. Calls to 999 in the West Midlands region are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP) and therefore we have no responsibility for making changes to this system. We are aware from West Midlands ambulance service that the matter has been raised with NHSP. We are however aware of the development of an educational e learning package for call handlers so they have a better understanding and awareness of Addison’s disease and steroid dependent patients. The package will be trialled in Yorkshire and is being developed in conjunction with The Pituitary Foundation.” Source location Response from Association of Ambulance
Open published response
15 Dec 2022 Neal Terence Saunders · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Inconsistent terminology for the ABD umbrella term across services View source Lack of paramedic guidance on the danger of prolonged restraint View source Lack of guidance defining prolonged restraint View source Lack of checking of infrequently used guidance View source Incorrect training about ambulance response categorisation for ABD View source Failure of classroom-based ABD training to be retained and embedded View source Unclear applicability of restraint guidance to people under arrest View source Incorrect training about chemical sedation by first responding ambulance staff View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Neal Terence Saunders · 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
Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology for the ABD umbrella term across services
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic guidance on the danger of prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint , and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of checking of infrequently used guidance
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed . The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about ambulance response categorisation for ABD
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of classroom-based ABD training to be retained and embedded
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received . I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively .
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded ?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of restraint guidance to people under arrest
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified ).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about chemical sedation by first responding ambulance staff
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Open source report
29 Nov 2022 Arthur Ronnie TROTT · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 3 Insufficient JRCALC guidance on emergency management of footling breech presentation View source Lack of ongoing obstetric teaching and training for ambulance services View source Lack of consultant midwife obstetric support and guidance across ambulance services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Arthur Ronnie TROTT · 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
Arthur Ronnie Trott died four days after an unexpected footling breech delivery at home, following a delay in transfer to hospital; the report states that this materially contributed to severe hypoxic ischaemic encephalopathy and his death. Concerns included insufficiently robust emergency guidance for footling breech presentations and limited consultant midwife support, guidance and training across ambulance services.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient JRCALC guidance on emergency management of footling breech presentation
Wider context from the report “1.The JRCALC guidance on the emergency management of footling breech presentation by the emergency services is insufficiently robust in that it should be recognised as different from other breech presentations and considered an acute obstetric emergency requiring immediate transfer to the nearest hospital obstetric unit . That is, no attempts should be made to attempt a home delivery due to difficulties with the baby's head not being able to be delivered.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing obstetric teaching and training for ambulance services
Wider context from the report “2. On evidence heard in court there are only two consultant midwives employed by the Ambulance services despite there being 11 Ambulance organisations within England. This leaves the majority of ambulances services having no obstetric support, guidance or ongoing teaching and training . As a matter of urgency there is a need to provide resources to employ more consultant midwives - at least one to two per service - throughout all the Ambulance organisations.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant midwife obstetric support and guidance across ambulance services
Wider context from the report “2. On evidence heard in court there are only two consultant midwives employed by the Ambulance services despite there being 11 Ambulance organisations within England . This leaves the majority of ambulances services having no obstetric support, guidance or ongoing teaching and training. As a matter of urgency there is a need to provide resources to employ more consultant midwives - at least one to two per service - throughout all the Ambulance organisations.
” Open source report
4 Nov 2022 Levi Louis Alleyne · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards View source Fragmented DNO emergency contact arrangements across ambulance service boundaries View source Delays to life-saving treatment due to uncertainty about whether OHPLs remain live View source Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators View source Risk to bystanders and emergency services from approaching patients near live OHPLs View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Levi Louis Alleyne · 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
Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off . There is no such instruction in the national Standard Operating Procedure .
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Fragmented DNO emergency contact arrangements across ambulance service boundaries
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact . There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries . Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand . The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO .
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Delays to life-saving treatment due to uncertainty about whether OHPLs remain live
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live . There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live ,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes . The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known .
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Risk to bystanders and emergency services from approaching patients near live OHPLs
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live .
” 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 Share updated ambulance-service SOPs, including electricity-network maps and distribution-network-operator contact details, across NHS ambulance services.
Verbatim wording from the response “I can confirm that actions taken by South Central Ambulance Service NHS Trust, to update their Standard Operating Procedures (SOPs) following the inquest, have been shared across all NHS ambulance services, including a map and the appropriate contact details for each of the electricity Distribution Network Operators. In addition, to reinforce the required steps, the matter is being discussed with all Heads of Emergency Operations Centres at their meeting in January 2023.” Source location Response from AACE
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 membership organisation can provide guidance and collaboration but cannot mandate NHS ambulance services to implement safety action.
Verbatim wording from the response “Please note, AACE is a membership organisation, subscribed to by all UK NHS ambulance services, and as such can offer guidance, encourage collaboration across services, and represent sector views, but cannot mandate action.” Source location Response from AACE
Open published response
5 Oct 2022 Charles Stephen Rothwell · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Lack of resources across primary, secondary and social care View source Delays in handing over ambulance patients at A&E departments View source Failure to match ambulance response capacity to demand View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charles Stephen Rothwell · 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
Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of resources across primary, secondary and social care
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care . This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Delays in handing over ambulance patients at A&E departments
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds , which in turn is because of shortages in social care.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to match ambulance response capacity to demand
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains , such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got .”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes , Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h .
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care.
” 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 Continue lobbying national bodies for changes to reduce hospital handover delays and improve ambulance capacity.
Verbatim wording from the response “This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem.” Source location Response from Association of Ambulance Chief Executives
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 System-wide causes of ambulance delays must be addressed nationally by NHS England, the Department of Health and Social Care, and the wider health system.
Verbatim wording from the response “As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.” Source location Response from Association of Ambulance Chief Executives
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 National demand-and-capacity modelling is to be led by NHS England rather than undertaken by the organisation.
Verbatim wording from the response “The second issue in play here is that we believe that ambulance services no longer have the required capacity nationally to routinely deliver the nationally mandated response time targets even if the current handover delay issues were eliminated. This is due to an inexorable rise in demand for our services and an increasing level of acuity in terms of the calls being received. AACE has flagged this issue nationally repeatedly over the last few years and has called for a national piece of demand and capacity modelling across the sector led by NHSE. I am pleased to say that this is now gaining traction and whilst in its early stages is being pursued by NHSE at the present time.” Source location Response from Association of Ambulance Chief Executives
Open published response
23 Mar 2022 Robert George MURRAY · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of understanding of circumstances when DNACPR should not be applied View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert George MURRAY · 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
Robert George MURRAY, who had mild dementia and lived in a nursing home, choked on food at breakfast on 10 June 2021 and died. An ambulance was not sent because he had a DNACPR in place; the concern was that those involved did not understand when a DNACPR should not be applied, indicating a need for further training and clarification.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of circumstances when DNACPR should not be applied
Wider context from the report “From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied . I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary.
” Open source report
27 Jan 2022 Adam Marshall Elliot STONE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to allow a category 1 ambulance response for severe ABD involving restraint View source
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
Adam Marshall Elliot STONE · 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
Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.
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× 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to allow a category 1 ambulance response for severe ABD involving restraint
Wider context from the report “5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk.
” 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 Consider whether restraint alone should trigger an automatic Category 1 response for suspected ABD.
Verbatim wording from the response “We agree that ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of agitation with likely physiological abnormalities, caused by one of a number of possible toxicological, physical, or mental health conditions. In the prehospital setting we are often unable to ascertain the exact cause of the presentation while providing clinical care prior to arrival at an emergency department. We considered whether the use of restraint alone should warrant an automatic Category 1 response, but this was agreed through the ECPAG process as not appropriate unless immediately life-threatening signs were present.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 Conduct a joint police and ambulance review of suspected ABD presentations to assess deterioration risk and appropriate response categories.
Verbatim wording from the response “To help inform this decision and provide evidence, a joint police and ambulance review was conducted in the north of England between one ambulance service and a police force for a period of 9 months between August 2019 to May 2020. The purpose of the joint review was to establish whether individual presenting features in patients who were identified by police officers on scene as possible ABD, might individually or in combination reliably identify an increased risk of clinical deterioration associated with increased mortality and to determine the most appropriate ambulance response time category. Police officers identified 28 potential ABD cases in the nine-month review period, representing 1% of the mental health or behavioural crisis 999 calls attended by the police” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 NHS England, through ECPAG, is responsible for deciding appropriate ambulance response categories.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 evidence-based arrangements consider Category 2 appropriate for suspected ABD unless immediately life-threatening signs warrant Category 1; restraint alone does not require Category 1.
Verbatim wording from the response “force. The review concluded that for patients who had been recognised as presenting with symptoms and signs of possible ABD, a Category 2 ambulance response was appropriate, if there was information that there were immediately life-threatening signs present, the patient should then receive a Category 1 ambulance response. The evidence and recommendations were accepted through the ECPAG process and implemented by all the UK ambulance services.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 AACE cannot decide or mandate emergency response categories and therefore cannot undertake that decision-making work.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
Open published response
4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions View source Failure to provide continuous monitoring and risk assessment of detainees subject to restraint View source Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks View source
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
LEON BRIGGS · 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
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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× 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
Wider context from the report “1. Adequacy of the local S136 Multi-Agency Policy
Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons:
(i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction)
(ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay ;
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end.
N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCG) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy making.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous monitoring and risk assessment of detainees subject to restraint
Wider context from the report “3. Adequacy of Monitoring of Detainees Subject to Restraint
The expert evidence of Dr ████████ (Consultant Intensivist). Professor ████████ (Consultant Cardiologist) and Dr ████████ (Forensic Pathologist) highlighted the effect that restraint has on detainees – not only in terms of the potential stress to the heart if the detainee struggles against such restraint but also in view of the continuing metabolic disturbance it creates which continues long after any restraint ceases or is removed. Indeed, they all agreed that metabolic disturbance from the restraint was one of the factors in causing Leon’s cardiac arrest and subsequent death. The evidence of Dr ████████ confirmed that the effects of the restraint would, however, have been treatable and that, if appropriate action had been taken, his cardiac arrest would likely have been avoided; indeed, he explained that even if action only had been taken at the point that Leon had become unconscious, the relatively simple steps of placing him in the recovery position in the cell and starting CPR, whilst awaiting emergency help, on the balance of probabilities, would have resulted in his survival.
The Jury through their answers to Questions 33-34 of the Jury Questionnaire not only determined that a failure to monitor Leon appropriately in the cell on 4 November 2013 more than minimally caused or contributed to his death but also concluded, in Box 3 of the Record of the Inquest, that “The inadequate continuous risk assessments and monitoring of Leon resulting in a failure to recognise when Leon became in need of urgent medical attention in the cell ” was one of the most serious failings by emergency services to provide Leon with adequate support.
Since the carrying out of even relatively basic first aid could have made a significant difference to the outcome in this case, it seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases . As the Jury found there were specific failures by the Custody team in this case, consideration could perhaps be given to having additional monitoring in respect of such detainees independent of the Custody team.
The NHS England Patient Safety Alert (2015) gives guidance to NHS staff on post-restraint observations: https://www.england.nhs.uk/wp-content/uploads/2015/12/psa-vital-signs-restrictive-interventions-031115.pdf. Although this has been circulated to some police, it may not be widely known about and even though it may not cover all of the situations which the police will encounter in their work, something similar could be of potential benefit to all police forces across the country.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks
Wider context from the report “2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders
Although, the MHCCG Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia . Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
” 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 Develop and publish national acute behavioural disturbance guidance addressing restraint minimisation, airway protection, de-escalation and patient monitoring.
Verbatim wording from the response “In the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines we developed and published a new guideline around acute behavioural disturbance in December 2019. The guideline highlights the importance of trying to minimise physical restraint for fewer than ten minutes and avoid airway or respiratory compromise. We are aware that factors have been proposed as contributory to sudden death in ABD and other types of intoxication such as amphetamines, positional asphyxia secondary to restraint, drug toxicity itself or underlying cardiac disease resulting in cardiac arrhythmias. We suggest that provided there is not an immediate risk to life, verbal de-escalation should be attempted before restraint or pharmacological agents are used.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 Revise, update and issue national Section 136 guidance addressing restraint information, response categorisation, clinical involvement and monitoring.
Verbatim wording from the response “With regard to your matter of concern about the adequacy of the local S136 Multi-Agency Policy. We are unable to comment on local S136 policy, but we can confirm that the national S136 guidance has recently been revised, updated, and issued nationally. The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1 response.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 Local ambulance trusts are responsible for determining the required training content and depth.
Verbatim wording from the response “With regard to your matter of concern around lack of sufficient training for police officers, ambulance crew and other front-line responders and the critical issues of recognising and responding to a medical emergency and the effects of restraint. We are unable to mandate the training that is required, nor the depth and degree of training. This is for local ambulance trust determination. However, we are very aware of the need for emphasis on and relevant training in this important area.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 organisation cannot mandate the content or depth of training required for frontline responders.
Verbatim wording from the response “With regard to your matter of concern around lack of sufficient training for police officers, ambulance crew and other front-line responders and the critical issues of recognising and responding to a medical emergency and the effects of restraint. We are unable to mandate the training that is required, nor the depth and degree of training. This is for local ambulance trust determination. However, we are very aware of the need for emphasis on and relevant training in this important area.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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 Local S136 policy is outside the scope of comment for this national ambulance organisation.
Verbatim wording from the response “With regard to your matter of concern about the adequacy of the local S136 Multi-Agency Policy. We are unable to comment on local S136 policy, but we can confirm that the national S136 guidance has recently been revised, updated, and issued nationally. The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1 response.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
Open published response
19 Jan 2021 Vhari Ingall · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information View source Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics View source Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making View source Failure to review TEP/DNAR documents when clinically significant diagnostic information changes View source Failure to limit Do Not Resuscitate document applicability to natural deaths View source See 2 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
Vhari Ingall · 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
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information.
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners . These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death, it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations .
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate . In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information .
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to review TEP/DNAR documents when clinically significant diagnostic information changes
Wider context from the report “During the Inquest into the death of Vhari I heard evidence from the Senior Partner of her GP surgery, New Court Surgery at Royal Wootton Bassett, Wiltshire as I had a concern in relation to the Treatment Escalation Plan/Do Not Resuscitation (“TEP/DNAR”) form which ████████ had completed with Vhari back in February 2017. I have enclosed a copy of that TEP/DNAR marked “A”. As you will see the reason for issuing it was that Vhari had been diagnosed, late during the previous year, with a pancreatic tumour and she was considered for palliative care only. Towards the end of 2017, the Consultant at Great Western Hospital in charge of her care, reviewed Vhari’s case and the diagnosis changed to one of chronic pancreatitis as opposed to a terminal tumour. This was confirmed in writing to the surgery on the 17 September 2017. During the course of ████████ evidence he explained to me the quite sensible reason why there is no fixed date review of these types of documents but did indicate that such a review was entirely appropriate when it was clinically appropriate to review the TEP/DNAR document. I was firmly of the view that a change in such a fundamental diagnosis should have ordinarily given rise to a review , however, I found no evidence that was recorded in Vhari’s case to suggest that such a review was undertaken by the surgery even though there was a number of consultations with different doctors following Mr. Payne’s letter of September 2017. The notes were completely silent as regards any such review being carried out . In fact I noted an entry in the records on the 5 March 2020 by one of the doctors at the surgery, ████████ who referred to “reminder/alert: DNAR-priority: high.” I also heard evidence from Vhari’s sister, ████████ that in going through Vhari personal possession she found no subsequent TEP/DNAR form after the February 2017 form.
I did consider sending a Regulation 28 Report to the surgery but heard evidence from ████████ that they now have provided by the local CCG an add on to their SystemOne system called an Arden’s module which assists in clinical decision making which they are also using in relation to recording TEP/DNARs. Whilst there is never a 100% guarantee that such a failure to review a document like this will not occur in the future and in respect of Vhari’s case it was in no way contributory to her death, I was satisfied that this step was an improvement and an attempt to mitigate against the risk of such a recurrence.
Obviously, this package is available to surgeries within my own coronial area, but I am unclear as to the position in other areas and obviously you have a greater awareness of these sorts of matters as part of your inspection processes.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to limit Do Not Resuscitate document applicability to natural deaths
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death , it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations.
” 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 Review and strengthen JRCALC guidance on resuscitation exceptions and DNACPR application.
Verbatim wording from the response “AACE, through NASMeD, has undertaken to review the JRCALC guidelines relating to the circumstances in which resuscitation attempts should not be undertaken, and the application of DNACPR forms, and strengthen the guidance in an attempt to prevent recurrence of these unfortunate situations. I trust that this response addresses your concerns.” Source location 2020-0084-Response-from-Association-of-Ambulance-Chief-Executives_Redacted-1
Open published response
16 Oct 2020 Sarah Fernyhough · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Automatic categorisation of abandoned calls as category 3 View source A ceiling of category 3 for categorisation of all reported medical conditions View source Failure to provide call recordings or full medical information to categorisation decision-makers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sarah Fernyhough · 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
Sarah Fernyhough died at home in the early hours of 22 May 2019 after taking an overdose of venlafaxine, amisulpride and hydroxyzine, as well as cocaine, cannabis and alcohol. The report identified a delay in ambulance attendance and concerns about the categorisation of her call, including the failure to ensure that the relevant call recording or full medical information was reviewed by the person able to upgrade its categorisation.
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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of abandoned calls as category 3
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required .
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation A ceiling of category 3 for categorisation of all reported medical conditions
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” 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 Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to provide call recordings or full medical information to categorisation decision-makers
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given . Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations