2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in updating electronic patient records with NHS 111 triage documents View source Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Variation in admission for observation of paediatric patients returning to the Emergency Department View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Alexander James Davidson · 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
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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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard , on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard . I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
” Open source report
9 Jan 2019 Diana Faith Gudgeon · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 7 Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system View source High call-holding threshold for triggering CMP 4 View source Failure to escalate calls when a urinary tract infection is suspected View source Failure of ‘111’ and EMAS call handling systems to treat neurological signs as urgent View source Failure of CMP statuses 1–3 to trigger deployment of additional vehicular resources View source Shortage of double crewed ambulances and fast response vehicles View source Unrestricted ability of a Technical Commander to downgrade a CMP status View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Diana Faith Gudgeon · 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
Diana Faith Gudgeon collapsed at home after being diagnosed with a water infection and remained on the floor for a prolonged period. Her call was assessed as requiring a category three response, and substantial delays followed before ambulance attendance, hospital admission and treatment; she died on 25 May 2018 despite treatment for infection and sepsis. The principal concerns were the triage and escalation of her call, shortages of ambulance resources, and the effectiveness of EMAS capacity management arrangements.
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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system
Wider context from the report “2. It was suggested in evidence that if the same facts are inputted into the ‘999’ AMPDS triaging system they are likely to allocate a higher priority to the call than the ‘111’ Pathway triaging system would .
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation High call-holding threshold for triggering CMP 4
Wider context from the report “4. The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, inter alia, the fact that:-
a) CMP status 1 – 3 does not trigger the deployment of additional vehicular resources.
b) CMP 4 is only triggered when 200 calls are holding (this was previously 150) – this is a high threshold .
c) A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding (CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate calls when a urinary tract infection is suspected
Wider context from the report “1. Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis. In the present case, Mrs Gudgeon had collapsed, passed out, been confused and had been vomiting. These are signs of central nervous system/neurological problems but were not regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract infection, no escalation occurred.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Failure of ‘111’ and EMAS call handling systems to treat neurological signs as urgent
Wider context from the report “1. Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis. In the present case, Mrs Gudgeon had collapsed, passed out, been confused and had been vomiting. These are signs of central nervous system/neurological problems but were not regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract infection, no escalation occurred.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Failure of CMP statuses 1–3 to trigger deployment of additional vehicular resources
Wider context from the report “4. The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, inter alia, the fact that:-
a) CMP status 1 – 3 does not trigger the deployment of additional vehicular resources.
b) CMP 4 is only triggered when 200 calls are holding (this was previously 150) – this is a high threshold.
c) A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding (CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Shortage of double crewed ambulances and fast response vehicles
Wider context from the report “3. The shortage of double crewed ambulances and fast response vehicles in the Northampton Division.
” 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 DHU 111 (East Midlands) CIC; that does not assign responsibility.
PFD Monitor interpretation Unrestricted ability of a Technical Commander to downgrade a CMP status
Wider context from the report “4. The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, inter alia, the fact that:-
a) CMP status 1 – 3 does not trigger the deployment of additional vehicular resources.
b) CMP 4 is only triggered when 200 calls are holding (this was previously 150) – this is a high threshold.
c) A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding (CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander.
” 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 Share concerns about NHS Pathways’ ability to identify possible sepsis with the software developers.
Verbatim wording from the response “Over the last year we have shared our concerns regarding NHS Pathways ability to pick up possible sepsis effectively and have fed our concerns back to them. This has resulted in changes to NHS Pathways in both versions 15 and 16. We have taken this call through NHS Pathways version 16 to try to identify the likely outcome had this version been in place at the time of the call. In version 16 the severely ill and new marks question has changed significantly. Firstly the 2 parts have now been split into separate questions. Due to concerns that the severely ill part of the question was too subjective this has been altered to “so ill they have stopped doing all normal activities”. The new marks part of the question is separate and triggered by answering the so ill they have stopped doing all normal activities question positively. The wording of the new marks part is unchanged.” Source location 2019-0015-Response-by-111-East-Midlands-CIC
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The triage systems would not have warranted a Category 2 ambulance without both severe illness and new marks being present.
Verbatim wording from the response “The call has been reviewed against NHS Pathways version 14, which was in use at the time of the call. The key question relates to whether the patient was severely ill. The response from the son was unclear in answering this question. The Health Advisor (who is trained in the use of NHS Pathways, but who is not a clinician) could have probed this question more appropriately by utilising the supporting clarification information within NHS Pathways in order to get a clearer answer to this question. However, in order for this question to have been answered positively there is a second part to the question which asks whether the patient has new marks like bruising or bleeding under the skin. Both severely ill and the new marks have to be present in order for this question to be answered positively.” Source location 2019-0015-Response-by-111-East-Midlands-CIC
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations