12 Mar 2020 Mitica Marin · Prevention of Future Deaths report East London
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Concerns raised 3 Failure to review the defibrillator during resuscitation View source LP15 defibrillator defaulting to manual mode View source Failure to activate the LP15 defibrillator in automatic mode View source
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AI-generated summary
Mitica Marin · 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
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
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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 Failure to review the defibrillator during resuscitation
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 LP15 defibrillator defaulting to manual mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 activate the LP15 defibrillator in automatic mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 resuscitation guidance on manual versus automatic defibrillation for the first cardiac arrest shock.
Verbatim wording from the response “Last year we undertook an extensive review of the resuscitation sections of our clinical practice guidelines. We considered the issue of using manual or automatic mode for delivering the first shock in a cardiac arrest situation and we issued our revised guidance to the UK ambulance services in June 2019. The section of our guidance pertaining to manual or automatic mode is detailed below:” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
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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 Issue revised guidance permitting solo responders to use automatic defibrillator mode until additional help arrives.
Verbatim wording from the response “Last year we undertook an extensive review of the resuscitation sections of our clinical practice guidelines. We considered the issue of using manual or automatic mode for delivering the first shock in a cardiac arrest situation and we issued our revised guidance to the UK ambulance services in June 2019. The section of our guidance pertaining to manual or automatic mode is detailed below:” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
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 Deciding or recommending which defibrillator ambulance services should purchase is outside the organisation’s responsibility as a membership organisation.
Verbatim wording from the response “We are aware that there are a number of types of defibrillators in use in UK ambulance service, however, it is not our responsibility as a membership organisation to decide or recommend which device an ambulance service should purchase.” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
Open published response
27 Jan 2020 Helen Jayne SHEATH · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3 Failure to code uncertain self-harm ingestion calls as Category 2 View source Failure to code uncertain self-harm ingestion calls as Category 2 View source Failure to maintain timely availability of a double staffed ambulance 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
Helen Jayne SHEATH · 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
Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.
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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 code uncertain self-harm ingestion calls as Category 2
Wider context from the report “(1) Helen’s father first called ambulance services at 18.20 hours on 2018 which was before he had ingested the sodium nitrate. EAS’s investigation report stated that “from the information provided on this call, that Helen had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled “Psychiatric/Abnormal Behaviour/Suicide Attempt” and the call was coded as a Category 3 . This call has been audited by the Quality Assurance Team and was correctly coded and the correct set of questions used” …yet a Category 3 call is for patients who have potentially urgent conditions that are not life threatening and yet Helen had a history of suicide ideation and her father was unable to tell, being the other side of the locked door, whether the substance had been taken or not. In view of both Helen’s past medical history and the fact that her father had no knowledge as to whether the substance had been ingested or not at that stage, it seemed to the Court that an assumption that an overdose had been taken ought to have been made and this first call, therefore, coded as a Category 2 ;
” 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 code uncertain self-harm ingestion calls as Category 2
Wider context from the report “(3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.
” 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 maintain timely availability of a double staffed ambulance
Wider context from the report “(2) Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call and it was only after a second call was made to ambulance services at 18.48 hours, when the call handler selected the set of questions titled “Overdose/Poisoning/Ingestion” because it was said that it was suggested on this call that she had ingested the substance that the call was coded a Category 2 and that, due to the lack of DSA availability , at 18.57 hours a Rapid Response Vehicle (RRV) was dispatched with the Mental Health Street Triage Team who arrived at 19.05 and 19.11 hours respectively with a different DSA arriving at 19.25 hours.
” 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 Encourage ambulance trusts to implement early clinical review of calls involving patients threatening suicide.
Verbatim wording from the response “A person that is threatening suicide does not constitute a life-threatening emergency and therefore doesn’t warrant a higher category of response but, given the potential for a small number of these cases to become potentially life threatening, early clinical review of these calls is recommended. NASMeD has previously encouraged all ambulance trusts to implement clinical review of these cases in support of the letter sent by Professor ████████ in April 2019.” Source location 2020-0107-Response-from-Association-of-Chief-Executives_Redacted.pdf
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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 Mandating or instructing ambulance services is outside the organisation’s constitution and authority.
Verbatim wording from the response “AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service however we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. One of our specialist sub groups is the National Ambulance Service Medical Directors (NASMeD) and this response therefore is from AACE and has been informed by NASMeD.” Source location 2020-0107-Response-from-Association-of-Chief-Executives_Redacted.pdf
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 ECPAG, an NHS England-led group, is responsible for approving changes to clinical code sets and response categories.
Verbatim wording from the response “The response categories are set by the Emergency Call Prioritisation Advisory Group (ECPAG), an NHS England led group responsible for the governance, control and approval of any change to clinical code sets (aligning codes to response categories).” Source location 2020-0107-Response-from-Association-of-Chief-Executives_Redacted.pdf
Open published response
27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 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
Shanté Andrée Marie TURAY-THOMAS · 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
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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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 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” 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 reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” 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 and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” 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 identify patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy 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 Lack of named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” 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 patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical advice .
” 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 the Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the 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 establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy 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 Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored in.
” 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 explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement .
” 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 Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” 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 healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.
” 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 communicate device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice .
” 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 NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective improvement .
” 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 AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” 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 the 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored in.
” 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 Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” 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 and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 advise prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” 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 display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” 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 Work with NHS England and other partners, and request resolution of inconsistent anaphylaxis coding between AMPDS and NHS Pathways.
Verbatim wording from the response “In line with the evidence you heard, at the time of this incident there was an inconsistency in the way in which AMPDS and NHS Pathways categorised anaphylactic shock. Whilst the technicalities of how the respective triage systems operate would be more appropriately commented on by others, it is worth noting that the tools have fundamentally different architecture and methods of operation. They are always likely to produce differing outcomes however we have worked closely with NHS England and other partners to reduce the variation as far as possible.” Source location 2020-0124-Association-of-Ambulance-Chief-Executives_Redacted.pdf
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 No remaining anaphylaxis categorisation inconsistency exists between NHS 111 and ambulance services because 111 incidents pass directly into ambulance dispatch.
Verbatim wording from the response “Your report makes the observation that inconsistency may remain in parts of the country where NHS Pathways is in use by the 111 provider and AMPDS is in use by the ambulance trust. I do not believe that is the case and, having consulted with clinical and operational colleagues within AACE, I cannot conceive of a circumstance where an incidence of anaphylaxis would be categorised as Cat 1 by the 111 provider but result in a different categorisation by the ambulance trust. Once categorised by 111 incidents are passed directly to the Computer Aided Dispatch (CAD) system of the ambulance trust bypassing any further call handling or other intervention. The incident would present as a Cat 1 to the ambulance dispatcher who would allocate an ambulance response.” Source location 2020-0124-Association-of-Ambulance-Chief-Executives_Redacted.pdf
Open published response
9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Failure to obtain complete medical and medication information from relevant sources View source Early exit from NHS Pathways Module 0 for third-party calls View source Failure to transfer important and accurate medical information to telecare and emergency services View source Lack of a facility for call handlers to pass calls directly to ambulance triage staff View source Lack of automatic flagging of medical and medication-related risks View source Failure of unanswered patient call attempts to trigger clinical review of triage decisions View source Different ambulance-call handling for third-party callers View source Unavailability of responder telephone numbers within the call handling system View source See 5 more concerns
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
John Michael WELLS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain complete medical and medication information from relevant sources
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Early exit from NHS Pathways Module 0 for third-party calls
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important and accurate medical information to telecare and emergency services
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record , which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for call handlers to pass calls directly to ambulance triage staff
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of medical and medication-related risks
Wider context from the report “(3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet.
I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure of unanswered patient call attempts to trigger clinical review of triage decisions
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Different ambulance-call handling for third-party callers
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back . Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Unavailability of responder telephone numbers within the call handling system
Wider context from the report “(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet).
Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not.
The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet.
” Open source report
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency 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 Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” 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 frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” 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 Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” 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 Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” 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 ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” 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 Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” 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 Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” 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 cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” 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 joint ambulance-police guidance for responding to suspected acute behavioural disturbance.
Verbatim wording from the response “ii) Joint guidance between the statutory ambulance services and the Police Forces is in development, overseen by a joint committee of AACE and the National Ambulance Commissioning Network, and supported by the ambulance and mental health group in NHS England. NASMeD has requested development of ambulance guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and these are due to be ratified shortly. The guidelines have been developed following consultation with the Faculty of Forensic and Legal Medicine (FFLM) and the Faculty of Pre-Hospital Care (FPHC).” Source location 2019-0352-Response-by-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 Ensure frontline ambulance and control-room staff are made aware of the new acute behavioural disturbance guidance after publication.
Verbatim wording from the response “iii) Following the publication of the JRCALC guideline on ABD there will be an expectation that all statutory ambulance services will ensure that their frontline staff are aware of, and concomitant with, its contents and ambulance control staff are also made aware of the new guidance.” Source location 2019-0352-Response-by-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 Work with police to improve information exchange and communications between ambulance and police control rooms.
Verbatim wording from the response “v) We do not believe that the absence of common terminology or the use of the term ‘on the hurry up’ was the issue. The ambulance response to all incidents are prioritised on information based on the patients presenting condition. Therefore it is essential to obtain appropriate information about the patient’s condition, and that this is passed from police to ambulance services in order to correctly prioritise the response and this will be our principal focus of ongoing work with the police. Once the new guidance on ABD has been ratified and issued and the trial in Yorkshire as described in point ii above has been completed, we will continue to discuss this in our work with the police to improve communications between ambulance and police control rooms.” Source location 2019-0352-Response-by-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 Annual ABD refresher training is considered disproportionate because cases are infrequent and paramedics must maintain broad competencies.
Verbatim wording from the response “iv) Annual refresher training in ABD is disproportionate given the incidence of these cases and the need to maintain and develop the broad range of competencies required of a frontline paramedic in a statutory ambulance service. We believe each of the English ambulance services receives two or three calls each week for patients with suspected ABD, amongst two to four thousand 999 calls per day. Whilst NASMeD or AACE is not in a position to mandate training requirements, we would not support a recommendation for annual refresher training on this subject.” Source location 2019-0352-Response-by-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 Information-passage arrangements between Police and Ambulance control rooms should be determined locally because technologies and working practices differ.
Verbatim wording from the response “AACE understand the cultural and practical barriers raised by the NPCC and accept that direct communication from the Police Officer on scene may not always be practicable. Ambulance trusts have locally agreed arrangements for the passage of information between Police and Ambulance control rooms. This is best determined at a local level due to differing technologies and working practices.” Source location 2019-0352-Response-by-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 Development of First Aid manual content falls outside NASMeD and AACE involvement, so they cannot assist with that matter.
Verbatim wording from the response “i) NASMeD, and the Association of Ambulance Chief Executives (AACE) as its parent body, have no involvement in the development of the content of First Aid manuals and are therefore unable to assist with this matter.” Source location 2019-0352-Response-by-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 Placing ambulance clinicians in Police control rooms has not proven an efficient operating model.
Verbatim wording from the response “vi) On the subject of cross working with emergency services, whilst we understand the motivation behind the evidence given, in practice, where ambulance trusts have placed clinicians in Police control rooms, it has not proven to be an efficient operating model. Improving communications and operating practices appears to be at the heart of this recommendation and we feel this would be best addressed through the arrangements to improve the joint working between police and ambulance services. As described in point v) above we would propose to develop this in close partnership with the police.” Source location 2019-0352-Response-by-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 Lack of common terminology or use of “on the hurry up” is not considered the cause of the ambulance response problem.
Verbatim wording from the response “v) We do not believe that the absence of common terminology or the use of the term ‘on the hurry up’ was the issue. The ambulance response to all incidents are prioritised on information based on the patients presenting condition. Therefore it is essential to obtain appropriate information about the patient’s condition, and that this is passed from police to ambulance services in order to correctly prioritise the response and this will be our principal focus of ongoing work with the police. Once the new guidance on ABD has been ratified and issued and the trial in Yorkshire as described in point ii above has been completed, we will continue to discuss this in our work with the police to improve communications between ambulance and police control rooms.” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
Open published response
24 Jul 2019 Maureen Woods · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event View source Insufficient resources for triage of all non-category 1 emergency calls 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
Maureen Woods · 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
Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.
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 Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event
Wider context from the report “(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times.
(2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response. However, resources do not permit each and every call to be triaged, and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need .
” 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 resources for triage of all non-category 1 emergency calls
Wider context from the report “(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times.
(2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response . However, resources do not permit each and every call to be triaged , and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need.
” Open source report
17 Jun 2019 Oliver Hall · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians View source Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children View source Failure to inform medical professionals of ambulance delays of 39 minutes or less View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Hall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.
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 transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
Wider context from the report “1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground .
In Oliver’s case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver’s actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician.
In response to their algorithms the NHS 111 Service implemented a disposition of ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service.
However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information .
The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’.
Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
” 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 and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children
Wider context from the report “3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee .
This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child .
Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normal range for a six-year-old child. The health professionals involved in Oliver’s case said they had relied on this guidance.
However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response . The health professionals involved in Oliver’s case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above.
Therefore, it is apparent that the significance of Oliver’s heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment , likely to be due to the nature of the conflicting guidance as detailed above.
” 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 inform medical professionals of ambulance delays of 39 minutes or less
Wider context from the report “2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call.
It was identified, that in a septicaemia case similar to Oliver’s (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2.
As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases).
Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less .
Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidly deteriorated.
As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating .
” 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 Ask JRCALC to consider whether evidence supports changing ambulance guidance on paediatric pulse-rate thresholds.
Verbatim wording from the response “Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff.” Source location 2019-0198-response-by-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 A pulse rate of 119 rather than 120 beats per minute would not independently influence assessment of a six-year-old child.
Verbatim wording from the response “Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be influential on its own. The attending ambulance staff have been taught that the assessment of the child with regard to severity of illness and possible causes would be influenced by a range of observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only by doing this that information received can be verified and form part of subsequent decision making.” Source location 2019-0198-response-by-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 is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.
Verbatim wording from the response “To clarify, AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service wherever we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.” Source location 2019-0198-response-by-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 Call takers cannot provide accurate expected arrival times because emergency responses are fluid and may be diverted to more urgent incidents.
Verbatim wording from the response “Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call taker to give accurate information regarding the expected time of arrival of a response. This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for a responding ambulance to be diverted from one emergency to another that has been assessed as more urgent or indeed for a responding ambulance to be flagged down at another incident they may be passing. For these reasons, call takers do not commit to an estimated time of arrival, rather they are asked to say ‘help is on its way and please ring back if the patient’s condition changes’.” Source location 2019-0198-response-by-Association-of-Ambulance-Chief-Executives
Open published response
17 Nov 2017 Kathryn Verina Richmond · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure to stagger ambulance crew shifts and meal breaks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathryn Verina Richmond · 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
Kathryn Verina Richmond collapsed at home on 21 April 2015, was taken to hospital after delays in ambulance attendance, and died that morning despite lifesaving treatment for a ruptured spleen. The principal concern was that non-staggered ambulance crew shifts led to simultaneous meal breaks, reducing available resources and potentially delaying responses to emergency calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association of Ambulance Chief Executives; that does not assign responsibility.
PFD Monitor interpretation Failure to stagger ambulance crew shifts and meal breaks
Wider context from the report “i. Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts , there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time .
” 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 Make the National Directors of Operations Group aware of the concerns and remind it to review rostering arrangements regularly.
Verbatim wording from the response “AACE will ensure that the National Directors of Operations Group (NDOG) is made aware of your concerns associated with this tragic incident and remind them of the need to ensure that this is done on a regular basis.” Source location 2017-0401-Response-by-Department-of-Health
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 Association lacks authority to mandate ambulance trusts to change their operating practices.
Verbatim wording from the response “Firstly, can I be clear that the Association of Ambulance Chief Executives (AACE) has no power to mandate Ambulance Trusts nationally to make changes to their operating practices which remain a matter for individual trusts and their respective Boards.” Source location 2017-0401-Response-by-Department-of-Health
Open published response
11 May 2016 Mia Gibson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to schedule ambulance crew meal breaks to maintain emergency availability View source Lack of training on placental abruption presentations and fetal risk despite reassuring maternal signs View source Insufficient availability of ambulance resources for urgent emergencies View source Failure to issue open-mic reports to mobilise available ambulance crews View source See 1 more concern
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
Mia Gibson · 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
Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.
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 schedule ambulance crew meal breaks to maintain emergency availability
Wider context from the report “3. Dispatchers appear to have allowed a situation to arise whereby the only 2 DCAs not attending other jobs were both on compulsory meal breaks and therefore unavailable at the same time . Whilst meal breaks are vital for staff, planning the timing of these, by ambulance control, is critical for patient safety . Meal break management is already under review by EMAS.
” 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 training on placental abruption presentations and fetal risk despite reassuring maternal signs
Wider context from the report “1. It appears that great reliance was placed on the fact that ████████ was not in pain and had normal observations. Little consideration appears to have been given to the ‘second patient’ (Mia), whose condition could not be monitored by paramedics. We heard evidence that in fact not all placental abruptions cause the mother significant pain, or concerning observations, but for the baby, it can be akin to a cardiac arrest. This factor appears to have been overlooked in the trust’s subsequent investigation report, which refers several times to how reassuring ████████ clinical condition was, and was repeated in evidence by the paramedic witnesses. This is a clear training issue, and may well apply nationally.
” 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 availability of ambulance resources for urgent emergencies
Wider context from the report “5. It is clear that resources played a part in these tragic events. No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that. The time between the 999 call and ████████ being handed over to maternity staff was an hour and 15 minutes. It was clear from the outset that ████████ would require urgent transfer to hospital – a mere 4 miles from her home address – but no resource was available. The evidence of those ‘on the ground’ clearly showed that this is far from an isolated incident , and I remain concerned that there is a risk of future deaths if this is not addressed .
” 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 issue open-mic reports to mobilise available ambulance crews
Wider context from the report “2. No ‘open mic’ report was put out to see if other crews could make themselves available to attend this emergency.
” Open source report
20 Mar 2015 Kingsley Burrell · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder View source Absence of a national multi-agency crisis team system for people in mental health crisis View source Lack of national training and understanding of how best to treat acute behavioural disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kingsley Burrell · 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
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
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 implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder
Wider context from the report “(3) This case has resulted in a multi-agency review of how patients are managed between the services when crisis occurs. A new conveying of patients policy has been devised. Critically police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward. My concern is that this is not reflected nationally . Chief Inspector ███████ at West Midlands Police can provide full details 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 Absence of a national multi-agency crisis team system for people in mental health crisis
Wider context from the report “(2) The West Midlands area now have a crisis team that works with people who are in a mental health crisis . This involves a mental health worker and ambulance crew working together with the Police to try to help patients with acute mental health disorders . My concern is that this is not a national system . Chief Inspector ███████ at West Midlands Police can provide full details of the scheme.
” 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 national training and understanding of how best to treat acute behavioural disturbance
Wider context from the report “(1) Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behaviour disturbance. As a result he continued to struggle against restraint. Patients with this condition are at risk of death through prolonged restraint and struggle against restraint. Most training in relation to restraint deaths focuses on positional asphyxia. Position in this case was not a major consideration. It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance . Minimising the period of restraint is key. West Midlands Police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it . I suggest contact is made with Chief Inspector Russell at WMP for full information on the changes made in the West Midlands area.
” 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 Work with the National Police Chiefs Council to ensure ambulances are requested for Section 136 incidents and reduce police conveyance.
Verbatim wording from the response “In the respect of the latter recent Home Office data indicates that for Section 136 where patients were conveyed by the Police 43% of cases were due to risk or behavioural issues and in 32% of cases no ambulance had been requested by the police. AACE continue to work with the NPCC to ensure that an ambulance is always requested and that police conveyance is reduced to as low a rate as possible.” Source location 2015-0472-Response-by-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 Continue working with police, Home Office and Department of Health partners to improve ambulance response speed and ambulance conveyance under Section 136.
Verbatim wording from the response “As a consequence ambulance trusts in England introduced new protocols in April 2014 designed to improve the speed of response to patients detained under Section 136 of the Mental Health Act in order to offer a clinical assessment more quickly and to arrange subsequent conveyance to a place of safety more efficiently. Data for 2014/15 indicates that there have been encouraging improvements with 74% of incidents where the police requested an ambulance receiving a response within 30 minutes. AACE continue to work with the NPCC, Home Office and the Department of Health to drive further improvements in both the speed of ambulance response and the proportion of patients conveyed by ambulance rather than police vehicles.” Source location 2015-0472-Response-by-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 National paramedic teams for acute mental health responses may be difficult to provide because of a recognised paramedic shortage and local commissioning arrangements.
Verbatim wording from the response “Due to a now recognised national shortage of paramedics, being able to provide a paramedic to specifically work as part of a team to respond to patients with acute mental health disorders will be difficult for some trusts, and will depend on local commissioning arrangements. We recognise that these schemes are likely to continue to develop.” Source location 2015-0472-Response-by-Association-of-Ambulance-Chief-Executives
Open published response
8 May 2014 Rajesh Parkash · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Inadequate communications between the London Ambulance Service and neighbouring ambulance services View source Limitation of supervising paramedic oversight to clinical decisions View source Lack of regular ongoing driver training beyond the statutory five-year assessment View source Inadequate communications between the control room and ambulance personnel answering a call View source Lack of a minimum experience requirement for supervising paramedics View source Failure to ensure timely staff awareness of Routine Information Bulletin updates and bulletins View source Failure of staff to understand that motorway driving measures and restrictions apply to all multi-lane highways View source See 4 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
Rajesh Parkash · 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
Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.
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 Inadequate communications between the London Ambulance Service and neighbouring ambulance services
Wider context from the report “7. Action is required to improve communications between the London Ambulance Service and those ambulance services which border its area , such as the South East Coast Ambulance Service.
” 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 Limitation of supervising paramedic oversight to clinical decisions
Wider context from the report “3. Consideration should be given to ensuring that the role of a supervising paramedic extends to all aspects of their work, including driving, and is not limited to clinical decisions .
” 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 regular ongoing driver training beyond the statutory five-year assessment
Wider context from the report “5. Consideration should be given to providing to all relevant staff regular, on-going driver training over and above the anticipated statutory requirement for a five year assessment .
” 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 communications between the control room and ambulance personnel answering a call
Wider context from the report “6. Action is required to improve communications between the control room and the personnel within an ambulance that is answering a call .
” 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 minimum experience requirement for supervising paramedics
Wider context from the report “4. Consideration should be given to imposing some form of minimum experience requirement before a paramedic is able to act in the role of a supervising paramedic .
” 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 timely staff awareness of Routine Information Bulletin updates and bulletins
Wider context from the report “1. Action is required to ensure that ALL updates and bulletins advertised on the Routine Information Bulletin are seen and read by all relevant members of staff in a timely manner .
” 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 staff to understand that motorway driving measures and restrictions apply to all multi-lane highways
Wider context from the report “2. Action is required to ensure that all relevant staff fully understand that the measures and restrictions included in the Trust’s training and guidance that apply to motorway driving apply equally to ALL multi-lane highways regardless of their designation .
” Open source report
9 Apr 2014 Sally Perrons · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient training on the use and interpretation of waveform end-tidal carbon dioxide monitors View source Lack of mandatory use of waveform end-tidal carbon dioxide monitors View source Failure to ensure that all relevant employees have read new guidelines, bulletins and SOPs View source Unavailability of waveform end-tidal carbon dioxide monitors to staff View source Insufficient initial and refresher training for paramedic intubation View source Failure to disseminate new guidelines, bulletins and SOPs to frontline staff View source See 3 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
Sally Perrons · 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
Sally Perrons collapsed at work on 22 January 2013 and was found to be in cardiac arrest. During resuscitation, an endotracheal tube was placed in her oesophagus, but this was not recognised until she reached hospital; she died the following day. The principal concerns were inadequate paramedic intubation training and refresher training, failure to use waveform end-tidal carbon dioxide monitoring, and poor dissemination of relevant guidance to frontline staff.
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 training on the use and interpretation of waveform end-tidal carbon dioxide monitors
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them .
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” 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 mandatory use of waveform end-tidal carbon dioxide monitors
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” 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 that all relevant employees have read new guidelines, bulletins and SOPs
Wider context from the report “5. (In relation to EMAS only) Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this .
” 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 waveform end-tidal carbon dioxide monitors to staff
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff , and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” 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 initial and refresher training for paramedic intubation
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” 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 disseminate new guidelines, bulletins and SOPs to frontline staff
Wider context from the report “5. (In relation to EMAS only) Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.
” 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 Implement annual reassessment of advanced airway skills using individual airway logs, performance frequency and problems encountered, including authority to continue intubation.
Verbatim wording from the response “• Annual re-assessment of the individual paramedic’s advanced airway skills will be based on the airway log, taking into account the number of times advanced airway skills such as intubation were performed and a review of any problems encountered. Authority to continue intubation will also be part of the assessment based on whether any airway management problems have arisen.
This action to be completed by July 2016.” Source location 2014-0158-Response-by-Association-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 Equip every paramedic-crewed responding vehicle with waveform capnography and train staff in its use.
Verbatim wording from the response “• The use of waveform capnography will be considered the gold standard but given that it will take up to three years time to procure this expensive equipment and train staff in its use this objective will take longer to achieve. We are however committed to having all this in place on every responding vehicle crewed by a paramedic as soon as is practically possible.
This action to be completed by July 2017.” Source location 2014-0158-Response-by-Association-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 Develop a nationally recognised teaching standard for stepwise airway management, ventilation and paramedic intubation competency.
Verbatim wording from the response “• Development of a national recognised teaching standard for the stepwise airway management and ventilation.
This will include airway positioning, simple adjuncts and advanced techniques which include supraglottic devices and paramedic intubation. This standard will describe how a paramedic will be initially trained and deemed competent to practice the skill of intubation.
This action to be completed by July 2015.” Source location 2014-0158-Response-by-Association-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 Require EtCO₂ detection to confirm every endotracheal tube placement and prohibit intubation without digital monitoring or waveform capnography equipment.
Verbatim wording from the response “• Confirmation of endotracheal tube placement will now include detection of EtCO₂. This will be mandatory for every intubation with immediate effect and initially will require the use of either a digital ETC02 monitoring device or the use of full waveform capnography. Paramedics will not be allowed to intubate patients where this equipment is not available to them and will need to manage the airway using alternative airway adjuncts.
This action to be completed with immediate effect.” Source location 2014-0158-Response-by-Association-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 Universal waveform capnography will take up to three years because equipment procurement and staff training are expensive and time-consuming.
Verbatim wording from the response “• The use of waveform capnography will be considered the gold standard but given that it will take up to three years time to procure this expensive equipment and train staff in its use this objective will take longer to achieve. We are however committed to having all this in place on every responding vehicle crewed by a paramedic as soon as is practically possible.
This action to be completed by July 2017.” Source location 2014-0158-Response-by-Association-Ambulance-Chief-Executives
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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 Each ambulance service will decide whether intubation remains a core skill or is restricted to specialised and advanced paramedics.
Verbatim wording from the response “• Each individual service will consider whether they continue in the future to teach intubation as a core skill or whether to restrict it to specialised and advanced paramedics. The survey did establish that two ambulance services have already decided that new graduate paramedics will not be practicing intubation in their Trusts.” Source location 2014-0158-Response-by-Association-Ambulance-Chief-Executives
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations