29 Sep 2014 Tiya Chetan Chauhan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of awareness of the choking risks of raw jelly cubes during play View source Absence of choking-risk warnings on packets of raw jelly View source Insufficient supervision of raw jelly play with young children View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Tiya Chetan Chauhan · 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
Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the choking risks of raw jelly cubes during play
Wider context from the report “(1) That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the especial risks of choking that a cube of raw jelly presents .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-risk warnings on packets of raw jelly
Wider context from the report “(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of raw jelly play with young children
Wider context from the report “(3) That raw jelly cubes may be used in play with young children without sufficient supervision .
” Open source report
Concerns raised 12 Limited Youth Offending Service staff training for the Social Services records system View source Insufficient capacity of supported accommodation View source Failure of frontline social services practitioners to identify when and where to make mental health referrals View source Lack of awareness among custody medical services of out-of-hours access to Children's Services records View source Failure to use previous psychiatric services information in assessment and Child in Need planning View source Inconsistent use of the Child in Need process for homeless young people View source Failure to routinely provide prisoner escort records to the Youth Offending Service View source Lack of a requirement for thorough mental health assessment of young people in custody View source Failure to obtain health-professional advice about risks following previous suicidal ideation View source Limited Youth Offending Service staff access to the Social Services records system View source Lack of a formal step-down process for young people leaving or disengaging from adult mental health services View source Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation View source See 9 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
Peter Stanley · 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
Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff training for the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity of supported accommodation
Wider context from the report “(7) This case shows the need for a greater number of places in supported accommodation .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of frontline social services practitioners to identify when and where to make mental health referrals
Wider context from the report “(9) It is evident that front line social services practitioners are not always aware of when and where to make mental health referrals .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among custody medical services of out-of-hours access to Children's Services records
Wider context from the report “(3) On the basis of evidence given by ████████ Assistant Director of Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have accessed the Children's Services records for Peter on 14 July, even during the night, by calling the Social Services 'out of hours' team. Every local authority has an out of hours system (which would cover adults as well). However I am told that this is not generally known amongst those providing custody medical 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to use previous psychiatric services information in assessment and Child in Need planning
Wider context from the report “(11) There is no system to ensure that where there has been previous psychiatric services involvement by a young person that such information will be used to inform assessment and the 'Child in Need' planning 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of the Child in Need process for homeless young people
Wider context from the report “(6) Peter was classed as 'intentionally homeless' after his release from court on 15 July. ████████ gave the court compelling evidence that this was wrong and that Peter should have been treated as a 'Child in Need'. Emphasis on the 'Child in Need' process when a young person is homeless would ensure proper assessment and sharing of information . Failures in sharing Peter's mental health history/needs were significant issues in this case . This emphasis is now standard practice in Sheffield but I understand it is not likely to be the case everywhere .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide prisoner escort records to the Youth Offending Service
Wider context from the report “(5) A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when Peter was produced before the magistrates. This contains details (inter alia) of risks, self harm issues, medical attention and warning markers. I understand that the Youth Offending Service believe that the PER should be routinely given to them it would inform assessments as to the immediate needs of the young person. This would only arise, of course, in the relatively few cases where the young person has spent a period in police cells.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for thorough mental health assessment of young people in custody
Wider context from the report “(4) There is no specific requirement that health professionals completing assessments of young persons in custody suites include a thorough assessment of mental health .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain health-professional advice about risks following previous suicidal ideation
Wider context from the report “(12) There is no system to ensure that when a young person has presented with previous suicidal ideology that advice is taken from health professionals regarding the potential risks .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff access to the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal step-down process for young people leaving or disengaging from adult mental health services
Wider context from the report “(2) When young people are discharged from, or have failed to engage with, Adult Mental Health Services there is no formal 'step-down' policy . The Sheffield Child Death Overview Panel advise me that this should include a referral to a Multi Agency Support Team or Community Youth team who can then establish a key worker and 'team around the child' approach.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation
Wider context from the report “(13) There is no system to ensure that 16 and 17 year olds placed in supported accommodation have needs based access to support services, including mental health and subsistence , irrespective of whether they fall within s.20 of the Childrens Act.
” Open source report
4 Feb 2014 Samuel Boon · Prevention of Future Deaths report South London
View report summary
Concerns raised 7 Failure to proactively obtain up-to-date participant medical information before departure View source Failure to include fitness, preparation, acclimatisation and medical-emergency evacuation risks in risk assessments View source Failure to fully assess, test and audit urgent evacuation procedures and facilities View source Limited availability of urgent evacuation to advanced medical facilities in remote expedition environments View source Failure to formally assess individual participants’ fitness for the activity View source Failure to provide sufficient and accurate trip participation and preparation information View source Failure to provide expedition and school leaders with sufficient heatstroke and hyponatremia information and training 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
Samuel Boon · 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
Samuel Boon, aged 17, collapsed from suspected exertional heatstroke and/or hyponatremia while trekking in high temperatures on a school trip in Morocco and died during a 25-minute journey to a local medical centre. Concerns included inadequate preparation and risk assessment, insufficient assessment of participants’ fitness and medical information, inadequate training about heatstroke and hyponatremia, and evacuation arrangements that had not been adequately assessed or equipped.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively obtain up-to-date participant medical information before departure
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure .
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to include fitness, preparation, acclimatisation and medical-emergency evacuation risks in risk assessments
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency .
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to fully assess, test and audit urgent evacuation procedures and facilities
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited . Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny .
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Limited availability of urgent evacuation to advanced medical facilities in remote expedition environments
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions , requiring urgent and appropriate evacuation to advanced medical facilities . In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible .
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess individual participants’ fitness for the activity
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity . There was an apparent onus on the parents and participants to assess fitness , though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient and accurate trip participation and preparation information
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip . Differences in ambulance and medical facilities in Morocco were not fully explained .
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred.
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to provide expedition and school leaders with sufficient heatstroke and hyponatremia information and training
Wider context from the report “(1) Preparation
• The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained.
• Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency.
• Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved.
• Up to date medical information about the participants was not proactively obtained shortly before departure.
Evacuation:
• Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible.
• Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred .
• Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely.
” Open source report
6 Dec 2013 Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient paediatric first aid training among nursery staff View source Failure of ambulance call-takers to correctly assess breathing and triage calls View source Lapsed first aid certification among staff 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
Millie Elizabeth Josephine Thompson · 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
Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient paediatric first aid training among nursery staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training , and that there is a need for specialist training when confronted with certain medical conditions affecting very young children . Other members of staff had general First Aid training but this appears to have been less useful in the circumstances .
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-takers to correctly assess breathing and triage calls
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated .
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lapsed first aid certification among staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time , so that although they had undergone the training it now needed updating .
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations