27 Jan 2022 Adam Marshall Elliot STONE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to allow a category 1 ambulance response for severe ABD involving restraint View source
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AI-generated summary
Adam Marshall Elliot STONE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to allow a category 1 ambulance response for severe ABD involving restraint
Wider context from the report “5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk.
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Propose that NHS England and AACE consider an evidence-based review of Acute Behavioural Disturbance response categorisation.
Verbatim wording from the response “I am aware that AACE will also be writing to you in response to your PFD. The College endorses the content of AACE’s letter to you. However, the College would always support an evidence-based review of the current response categorisation of Acute Behavioural Disturbance in order to ensure that a Category 2 response remains the appropriate disposition and I will share this correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose that such a review be considered in the light of this PFD.” Source location 2022-0026-Response-from-College-of-Paramedics_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for determining NHS ambulance response categories lies with NHS England, supported by AACE evidence and guidance.
Verbatim wording from the response “The College of Paramedics is also not responsible for determining NHS ambulance response categories. That power lies with NHS England, although the Association of Ambulance Chief Executives (AACE) provide evidence and guidance to support this.” Source location 2022-0026-Response-from-College-of-Paramedics_Published
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30 Mar 2015 Sabrina Stevenson · Prevention of Future Deaths report Inner North London
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Concerns raised 15 Variation in paramedic training View source Failure to implement or consider automated call recategorisation View source Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues View source Failure to provide call-handlers with feedback on current time-frames View source Failure to address increasing ambulance response times View source Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain View source Insufficient availability of trained paramedics due to vacant positions View source Shortfalls in the ability to undertake internal investigations View source Failure of pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain View source Insufficient crew knowledge of alternative patient extraction techniques View source Failure to progress a pre-hospital validated early warning score system View source Failure to implement or consider clinical re-triaging View source Failure to address increasing ambulance response times View source Lack of steps to take forward a pre-hospital validated early warning score system View source Unaddressed ambulance service staffing vacancies View source See 12 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sabrina Stevenson · 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
Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.
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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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Variation in paramedic training
Wider context from the report “(3) A related issue was raised at the inquest, regarding whether the increasingly complex clinical role of paramedics means that they should be recruited through graduate, rather than vocational schemes. I am sufficiently concerned by the apparent variation in training that I consider this issue to warrant consideration;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to implement or consider automated call recategorisation
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation , clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points , I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to provide call-handlers with feedback on current time-frames
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain
Wider context from the report “(4) Concern has been raised by Sabrina’s family, with whom I concur, that the Manchester Triage System should reflect the evidence of the consultant Gynaecologist ; that any woman of child-bearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing .
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of trained paramedics due to vacant positions
Wider context from the report “(2) I am concerned by evidence provided from LAS that there are 400 vacant positions within the Trust . This connotes a significant recruitment issue for the profession , which could risk future deaths occurring simply through a lack of available trained paramedics ;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Shortfalls in the ability to undertake internal investigations
Wider context from the report “(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations . Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain . It is clear that the Trust are taking further steps to address this; however, more detailed information as to time-frames and progress in this regard are required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure of pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene ;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Insufficient crew knowledge of alternative patient extraction techniques
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance ;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to progress a pre-hospital validated early warning score system
Wider context from the report “(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view ;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to implement or consider clinical re-triaging
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Failure to address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Lack of steps to take forward a pre-hospital validated early warning score system
Wider context from the report “(1) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view and I believe that the College of Paramedics may be in a position to assist in this process;
” 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 College of Paramedics; that does not assign responsibility.
PFD Monitor interpretation Unaddressed ambulance service staffing vacancies
Wider context from the report “(2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions , without further detail as to what steps are being taken to address this shortfall ;
” 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 Apply for student paramedics to be included in the NHS Bursary Scheme.
Verbatim wording from the response “2. The College made application to the Department of Health on 16 August 2012 for student paramedics to be included in the NHS Bursary Scheme and the final decision is due to be recommended to the Department of Health by HEE in June 2015” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to ambulance services and higher education institutions offering assistance with paramedic recruitment activities.
Verbatim wording from the response “2. We will write to all NHS ambulance services as employers of paramedics and to HEIs to offer our assistance in their activities which aim to recruit student paramedics and paramedics. We will do this by 5 June 2015” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund the Paramedic Evidence-based Education Project, supporting subsequent national review of its recommendations.
Verbatim wording from the response “This coupled with the fact there has been wide variation in courses and awards leading to paramedic qualification led to the College funding the Paramedic Evidence-based Education Project (PEEP) in 2012 which has since led to a major project being led by Health Education England (HEE). The Chair of the College of Paramedics has co-chaired the HEE PEEP Steering Group, and senior College members have provided representation into its sub-groups. The recommendations from the Steering Group are due to be published in June 2015 following approval by the Department of Health.” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the Consultant Gynaecologist’s pregnancy-triage recommendation with JRCALC and request its inclusion in the scheduled workstream agenda.
Verbatim wording from the response “1. The College of Paramedics will advise the JRCALC of the recommendation made by the Consultant Gynaecologist and propose that this work is scheduled into the JRCALC workstream. As in our actions for concern (1) we will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue promoting paramedic careers through the College website.
Verbatim wording from the response “1. Through our website, we will continue to promote the paramedic profession as an attractive and rewarding career;” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in national working groups or committees developing and establishing an early warning system compatible with receiving health facilities.
Verbatim wording from the response “2. The College of Paramedics will participate on any working groups or committees that might be convened at a national level to develop and establish an effective national early warning system that can be applied in pre-hospital care and which would be compatible with receiving health facilities.” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise a national pre-hospital early warning system with JRCALC and request its inclusion in the scheduled workstream agenda.
Verbatim wording from the response “1. As a member of the JRCALC, the College of Paramedics will raise the issue of a national early warning system with the JRCALC and propose that this work is scheduled into the JRCALC workstream. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a clinical case study and expert commentary on potential ruptured ectopic pregnancy in the August 2015 newsletter.
Verbatim wording from the response “1. The College of Paramedics will include a clinical case study and expert commentary on potential ruptured ectopic pregnancy in its August 2015 newsletter which will aim to increase awareness of the risks associated with such cases” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish revised Paramedic Curriculum Guidance, post-registration career framework and Scope of Practice Policy after addressing independent and HEE comments.
Verbatim wording from the response “As part of the HEE PEEP Steering Group work, a review of the College of Paramedics' Paramedic Curriculum Guidance, the College of Paramedics Paramedic Post Registration – Career Framework, and the College of Paramedics Scope of Practice Policy was reviewed by an independent body [Institute of Education]. This was to ensure parity with other Allied Health Professions and confirm that the Paramedic Curriculum Guidance was at the appropriate Higher Education standard. The College of Paramedics has addressed the comments raised by both the independent body and HEE and the revised documents will be published in May or June 2015.” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to ambulance services and higher education institutions about the revised curriculum guidance and offer course-development assistance through the endorsement process.
Verbatim wording from the response “1. The College of Paramedics will write to the ambulance services and HEIs advising of the revised Paramedic Curriculum Guidance once published and offer our assistance in course development through the availability of the College's course endorsement process. We will write to those organisations by the 30th June 2015.” Source location 2015-0126-Response-by-College-of-Paramedics
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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 explore incorporating formalised triage tools into the next clinical practice guideline iteration.
Verbatim wording from the response “2. The College of Paramedics will take the issue of triage tools, such as the Manchester Triage System and Paramedic Pathfinder to the JRCALC and propose that work is undertaken to explore the inclusion of formalised triage tools into the next iteration of the JRCALC clinical practice guidelines. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College lacks regulatory powers to ensure paramedics, ambulance services or higher education institutions adopt its guidance.
Verbatim wording from the response “While the College has no regulatory powers or authority to ensure paramedics, the UK ambulance services or higher education institutions take up the guidance it produces, it works closely with several other organisations which have important roles in setting standards and determining clinical practice. The most significant of those are briefly described below:” Source location 2015-0126-Response-by-College-of-Paramedics
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College does not commission paramedic education, limiting its role in addressing paramedic recruitment and training capacity.
Verbatim wording from the response “The College of Paramedics does not commission education for paramedics. However, the College has previously responded to consultations by the Centre for Workforce Intelligence (CfWI) and has noted that in early 2015 the Migration Advisory Committee has recommended that paramedics qualified to NQF 6+ should be included in the shortage occupation list.” Source location 2015-0126-Response-by-College-of-Paramedics
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations