Concerns raised 3 Lack of an ABD protocol between police forces and the local ambulance service View source Allocation of ABD referrals to only a category 2 response in the absence of police restraint View source Lack of an NHS Pathways allocation pathway for ABD View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Shaun GRACEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an ABD protocol between police forces and the local ambulance service
Wider context from the report “1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such protocol in Lincolnshire .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Allocation of ABD referrals to only a category 2 response in the absence of police restraint
Wider context from the report “3. Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response in the absence of police restraint .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an NHS Pathways allocation pathway for ABD
Wider context from the report “2. Under the current NHS Pathways system, ABD does not have its own allocation pathway .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue participating in the Police Regional Clinical Governance Forum to align ABD training and response protocols.
Verbatim wording from the response “The Trust currently operates across six counties within the East Midlands, creating logistical hurdles when ensuring policies and response protocols are consistent across multiple counties and multiple police forces. The Trust will, however, continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Maintain the Emergency Call Handling Protocols process governing responses to suspected ABD incidents.
Verbatim wording from the response “In addition, the Trust recognises that there is not currently a national pathway for ABD, however the Trust has in place a process for a response to ABD as governed by the Emergency Call Handling Protocols that was ratified by the” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with regional police forces and health partners to explore a single joint operational framework for ABD management.
Verbatim wording from the response “The Trust will also continue to work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Changing the nationally mandated NHS Pathways system to create an ABD pathway must be initiated by NHS England.
Verbatim wording from the response “The Future” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
6 Jan 2026 Adam Ali Hussain · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS View source Failure to inform waiting families when an ambulance will not be sent View source Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adam Ali Hussain · 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 Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families when an ambulance will not be sent
Wider context from the report “3. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information
Wider context from the report “2. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
” 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 Submit a supplier development request for automated text notifications when calls are transferred through the Interoperability Toolkit.
Verbatim wording from the response “The current CAD system does not provide an automatic mechanism for notifying callers in these circumstances. To address this, EMAS has submitted a development request to the system supplier (MIS). The planned enhancement will ensure that, when a call is transferred through the Interoperability Toolkit (ITK), the caller receives a text message confirming the status of their request. The proposed message will be as follows:” Source location Response from East Midlands Ambulance Service NHS Trust
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 Implement automated text notifications confirming request status when calls are transferred through the Interoperability Toolkit.
Verbatim wording from the response “The current CAD system does not provide an automatic mechanism for notifying callers in these circumstances. To address this, EMAS has submitted a development request to the system supplier (MIS). The planned enhancement will ensure that, when a call is transferred through the Interoperability Toolkit (ITK), the caller receives a text message confirming the status of their request. The proposed message will be as follows:” Source location Response from East Midlands Ambulance Service NHS Trust
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 clinicians to review available information and make all Category 3 transfers through a clinical-only process, ending manual pushes to NEMS.
Verbatim wording from the response “Historically, non-clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, EMAS implemented a significant change to operational practice:” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a technological solution with partner organisations to transfer complete patient information across urgent-care services.
Verbatim wording from the response “required. To address this, EMAS has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision-making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation View source Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls View source Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Failure to inform waiting families that an ambulance will be sent View source Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service 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
Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls
Wider context from the report “5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call , including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition is reached is for a Category 3 ambulance response
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families that an ambulance will be sent
Wider context from the report “3. Families, waiting for an ambulance response , following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will be sent
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
Wider context from the report “2. There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS .
” 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 a technological solution with partner organisations to transfer complete patient information across urgent care services.
Verbatim wording from the response “The Trust recognises that, while the urgent care pathway performs well for most patients, those presenting with serious but not immediately life-threatening systemic illness may not be supported as effectively as required. To address this, the Trust has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision-making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
Verbatim wording from the response “In December 2025, the Trust upgraded its CAD system to ensure that all information captured during the initial 999 call is automatically transmitted to subsequent receiving systems. This enhancement has been fully tested with the Trust and NEMS and now supports the transfer of more comprehensive clinical information at the point of referral.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Introduce CAD functionality that texts callers confirming the status of requests transferred through the Interoperability Toolkit.
Verbatim wording from the response “The current CAD system does not provide an automatic mechanism for notifying callers in these circumstances. To address this, the Trust has submitted a development request to the system supplier (MIS). The planned enhancement will ensure that, when a call is transferred through the Interoperability Toolkit (ITK), the caller receives a text message confirming the status of their request. The proposed message will be as follows:” Source location Response from East Midlands Ambulance Service NHS Trust
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 clinicians to review available information and make all Category 3 transfers through the clinical push model.
Verbatim wording from the response “Historically, non-clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, the Trust implemented a significant change to operational practice:” Source location Response from East Midlands Ambulance Service NHS Trust
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 Submit a development request to the CAD supplier for caller text notifications when calls are transferred through the Interoperability Toolkit.
Verbatim wording from the response “The current CAD system does not provide an automatic mechanism for notifying callers in these circumstances. To address this, the Trust has submitted a development request to the system supplier (MIS). The planned enhancement will ensure that, when a call is transferred through the Interoperability Toolkit (ITK), the caller receives a text message confirming the status of their request. The proposed message will be as follows:” Source location Response from East Midlands Ambulance Service NHS Trust
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 current CAD system cannot automatically notify families when an ambulance will not be sent, pending supplier development of this functionality.
Verbatim wording from the response “3. Families awaiting an ambulance following a 111 clinical assessment are not informed by EMAS if an ambulance will not be sent.” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
30 Oct 2025 Mr Gunaratnam Kannan · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments View source Lack of training of service providers on the process for referrals for Mental Health Act assessments View source Lack of training of service providers on Mental Capacity Act assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Gunaratnam Kannan · 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
Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on the process for referrals for Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on Mental Capacity Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Mental Health Awareness training and seek Mental Health Trust input to align it with formalised referral pathways.
Verbatim wording from the response “Supporting tools such as non-conveyance checklists and MCA prompts are embedded within our patient record system to guide staff in practice. Furthermore, all front-line crews undertake Mental Health Awareness training every two years, covering statutory detention processes, roles, and current pathways. This training is under review for January 2026, and we will seek input from Mental Health Trust partners to ensure alignment with formalised pathways for MHA assessments.” Source location Response from East Midlands Ambulance Service
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 Participate in quarterly system meetings to review clinical and operational responsibilities and identify service provision gaps.
Verbatim wording from the response “Locally, EMAS participates in a quarterly Right Care Right Person Meeting led by Nottingham and Nottinghamshire Integrated Care Board, alongside system partners, to review clinical and operational responsibilities and identify gaps in service provision. Following the inquest, a wider multi-agency group has been convened to specifically consider how to strengthen decision-making and pathways between agencies when considering the mental health act and the mental capacity act.” Source location Response from East Midlands Ambulance Service
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 Work through a multi-agency group to strengthen decision-making and inter-agency pathways for Mental Health Act and Mental Capacity Act matters.
Verbatim wording from the response “Locally, EMAS participates in a quarterly Right Care Right Person Meeting led by Nottingham and Nottinghamshire Integrated Care Board, alongside system partners, to review clinical and operational responsibilities and identify gaps in service provision. Following the inquest, a wider multi-agency group has been convened to specifically consider how to strengthen decision-making and pathways between agencies when considering the mental health act and the mental capacity act.” Source location Response from East Midlands Ambulance Service
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 Provide biennial Mental Health Awareness training covering statutory detention processes, roles and current pathways.
Verbatim wording from the response “Supporting tools such as non-conveyance checklists and MCA prompts are embedded within our patient record system to guide staff in practice. Furthermore, all front-line crews undertake Mental Health Awareness training every two years, covering statutory detention processes, roles, and current pathways. This training is under review for January 2026, and we will seek input from Mental Health Trust partners to ensure alignment with formalised pathways for MHA assessments.” Source location Response from East Midlands Ambulance Service
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 Provide statutory education supporting clinicians to conduct Mental Capacity Act assessments.
Verbatim wording from the response “EMAS has a robust education programme to support clinicians in conducting mental capacity assessments. All clinical staff receive relevant training as part of their core qualification (e.g., paramedic courses), supplemented by safeguarding education, which includes MCA principles within a rolling statutory programme.” Source location Response from East Midlands Ambulance Service
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 and implement formal referral pathways with mental health trusts for mental health assessments.
Verbatim wording from the response “Ambulance crews are not mental health specialists and therefore cannot determine whether a statutory MHA assessment is required. At present, EMAS does not have formalised referral pathways with local crisis teams; however, we are actively working with mental health trusts to develop and implement these pathways.” Source location Response from East Midlands Ambulance Service
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 Ambulance crews cannot determine whether a statutory Mental Health Act assessment is required because they are not mental health specialists.
Verbatim wording from the response “Ambulance crews are not mental health specialists and therefore cannot determine whether a statutory MHA assessment is required. At present, EMAS does not have formalised referral pathways with local crisis teams; however, we are actively working with mental health trusts to develop and implement these pathways.” Source location Response from East Midlands Ambulance Service
Open published response
28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 7 Delays in transferring patients from the Emergency Department into wards View source Failure to provide interim safety guidance while awaiting ambulance arrival View source Delays in ambulance-to-hospital handover View source Delays in medically trained clinician review of ambulance call information View source Delays in transferring ambulance patients into the Emergency Department View source Failure to adequately record and accurately and completely convey symptom information View source Failure to base triage category changes on evidence of clinical change or deterioration 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
Lewis Aubrey GARFIELD · 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
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients from the Emergency Department into wards
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards , causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide interim safety guidance while awaiting ambulance arrival
Wider context from the report “c) The family complained of not being given any guidance on how to deal with the patient pending the arrival of an ambulance e.g. not to move him given the fall down the stairs .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance-to-hospital handover
Wider context from the report “d) I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes. However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours . The Trust lost 115 hours waiting to handover at Northampton over 121 hours at Kettering.
e) I heard evidence that steps are being taken to mitigate the impact of pressures in the healthcare system. University Hospitals of Northamptonshire have adopted the ‘45-minute handover’ approach. Despite this, on the day of the inquest on 27 October 2025, average handover times at Northampton General Hospital were 1 hour 11 minutes and I suspect that this will get worse during the full onset of winter pressures.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medically trained clinician review of ambulance call information
Wider context from the report “b) The first call was at around 00:44 hours but it was not until over 4 hours later at 05:05 hrs that a medically trained clinician first reviewed the facts , immediately escalating it to category 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring ambulance patients into the Emergency Department
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED , and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and accurately and completely convey symptom information
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to base triage category changes on evidence of clinical change or deterioration
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” 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 Initiate and record rapid or immediate hospital handover requests during high-demand periods under the safe-handover escalation procedure.
Verbatim wording from the response “The Trust proactively initiates ‘rapid handover’ requests during periods of high demand, particularly when multiple hospital handover delays coincide with uncovered Category 2 emergency calls. These actions are guided by our ‘Managing Delays in the Safe Handover of Patients’ Standard Operating Procedure, which incorporates a series of triggers aligned with the NHSE Midlands Region agreed process.” Source location Response from East Midlands Ambulance Service
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 Implement the 45-minute ambulance handover protocol with acute, commissioning and national healthcare partners through weekly oversight meetings.
Verbatim wording from the response “Persistent delays across the system have led to the introduction of an additional operational measure known as the 45-minute handover ceiling. This is also in this year’s 2025/26 planning guidance and Urgent Emergency Care recovery plan. Under this policy, if a patient has not been formally handed over within 45 minutes, ambulance crews are required to complete a safe transfer process and leave the patient in the care of hospital staff. This includes ensuring the patient is placed in an appropriate location (such as a trolley, chair, or designated waiting area) and that essential clinical information is communicated to ED personnel. The purpose of this measure is to prevent excessive delays that compromise ambulance availability and community response times for life-threatening incidents.” Source location Response from East Midlands Ambulance Service
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 Direct patients dynamically to hospitals outside their usual catchment areas when necessary to reduce handover delays and restore ambulance availability.
Verbatim wording from the response “Within the Northamptonshire division, the Trust are now implementing dynamic strategic conveyance on a daily basis, directing patients to hospitals outside their usual catchment area when necessary. This approach helps mitigate the impact of excessive handover delays at pressured acute sites, reducing lost time and enabling crews to return promptly to attend patients in the community.” Source location Response from East Midlands Ambulance Service
Open published response
25 Sep 2025 Zara Alice Cheesman · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Insufficient audit and monitoring of operational staff by senior clinical staff View source Lack of detailed organisational understanding of the extent of identified issues View source Insufficient continuing professional development for assessment of sick children and young people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zara Alice Cheesman · 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
Zara Alice Cheesman died in hospital on 23 December 2024 from meningococcal meningoencephalitis after becoming progressively unwell. The report identified concerns about inadequate assessment and non-conveyance by ambulance staff on 21 December, alongside insufficient organisational oversight, audit, monitoring and continuing professional development for assessing seriously ill children.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit and monitoring of operational staff by senior clinical staff
Wider context from the report “1. There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made
2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff , to ensure there is both understanding and following of key EMAS guidelines
3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person)
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed organisational understanding of the extent of identified issues
Wider context from the report “1. There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made
2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines
3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person)
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient continuing professional development for assessment of sick children and young people
Wider context from the report “1. There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made
2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines
3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people , with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person)
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 Host multidisciplinary workshops to inform and shape future continuing professional development offerings.
Verbatim wording from the response “In 2025–26, we have prioritised education on safe conveyance decisions involving children and young people. We have also hosted multidisciplinary workshops to gather staff insights and shape future CPD offerings. Registered clinicians benefit from access to ParaPass and ParaFolio, which digitally support guideline-aligned learning and portfolio development.” Source location Response from East Midlands Ambulance Service
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 Introduce compliance tracking for clinical bulletins within performance monitoring arrangements.
Verbatim wording from the response “We have expanded our clinical audit programme to include mandatory reviews of paediatric care episodes. This ensures that both remote and face-to-face interactions are assessed for adherence to clinical guidelines.
To enhance oversight, we have introduced compliance tracking for clinical bulletins and integrated this into our performance monitoring structures.” Source location Response from East Midlands Ambulance Service
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 Prioritise education on safe conveyance decisions involving children and young people during 2025–26.
Verbatim wording from the response “In 2025–26, we have prioritised education on safe conveyance decisions involving children and young people. We have also hosted multidisciplinary workshops to gather staff insights and shape future CPD offerings. Registered clinicians benefit from access to ParaPass and ParaFolio, which digitally support guideline-aligned learning and portfolio development.” Source location Response from East Midlands Ambulance Service
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 Reinforce education on appropriate use of physiological scoring systems through annual training and point-of-care guidance.
Verbatim wording from the response “We have reinforced education around the appropriate use of physiological scoring systems, including NEWS2, through our annual training programmes and point-of-care guidance. A Trust-wide education initiative focused on paediatric conveyance decisions has been launched, supported by staff engagement events and a newly established working group to review policy effectiveness.” Source location Response from East Midlands Ambulance Service
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 Adopt the UK Sepsis Trust standardised tool for paediatric sepsis assessment and management.
Verbatim wording from the response “To ensure immediate impact, we have issued a clinical bulletin outlining essential paediatric care principles, including mandatory referral protocols for non-registered and newly qualified staff. Additionally, we have adopted the UK Sepsis Trust’s standardised tool for paediatric sepsis assessment and management.” Source location Response from East Midlands Ambulance Service
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 Issue a clinical bulletin setting out paediatric care principles and mandatory referral protocols for non-registered and newly qualified staff.
Verbatim wording from the response “To ensure immediate impact, we have issued a clinical bulletin outlining essential paediatric care principles, including mandatory referral protocols for non-registered and newly qualified staff. Additionally, we have adopted the UK Sepsis Trust’s standardised tool for paediatric sepsis assessment and management.” Source location Response from East Midlands Ambulance Service
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 Launch trust-wide education on paediatric conveyance decisions, supported by staff engagement events.
Verbatim wording from the response “We have reinforced education around the appropriate use of physiological scoring systems, including NEWS2, through our annual training programmes and point-of-care guidance. A Trust-wide education initiative focused on paediatric conveyance decisions has been launched, supported by staff engagement events and a newly established working group to review policy effectiveness.” Source location Response from East Midlands Ambulance Service
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 Review clinical governance, leadership and supervision arrangements for paediatric care.
Verbatim wording from the response “Under the leadership of our new Clinical Director the organisation is reviewing our approach to clinical governance, leadership and supervision. Senior clinicians in the Trust have been appointed to lead specific areas including a lead for children and young people. We acknowledge the shortcomings in the assessment and conveyance decisions in Miss Cheesman’s case and EMAS is now strengthening its systems to ensure robust paediatric assessment and decision-making by our frontline clinical teams. All staff have access to the national ambulance clinical guidelines published by the Joint Royal Colleges Ambulance Liaison Committee (known as the JRCALC app) and these include specific guidance for febrile illness in children and medical emergencies in children.” Source location Response from East Midlands Ambulance Service
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 Provide age-appropriate paediatric assessment tools through the electronic patient record system.
Verbatim wording from the response “These form the basis of our educational content and clinical practice. In addition, all clinical staff have access to age-appropriate clinical tools via our electronic patient record system (ePRF), including the Paediatric Observation Priority Score (POPS2), implemented in collaboration with East Midlands Acute Trusts.” Source location Response from East Midlands Ambulance Service
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 Expand clinical audits to mandate reviews of remote and face-to-face paediatric care episodes against clinical guidelines.
Verbatim wording from the response “We have expanded our clinical audit programme to include mandatory reviews of paediatric care episodes. This ensures that both remote and face-to-face interactions are assessed for adherence to clinical guidelines.
To enhance oversight, we have introduced compliance tracking for clinical bulletins and integrated this into our performance monitoring structures.” Source location Response from East Midlands Ambulance Service
Open published response
Concerns raised 11 Lack of police training for mental health-related incidents involving illicit substance use View source Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests View source Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain View source Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy View source Failure of police training on ambulance conveyance for s.136 detainees View source Lack of police training on communicating s.136 detention decisions and reasons View source Lack of an out-of-hours local protocol for police access to mental health advice View source Lack of joined-up agency policy for s.136 detention and conveyance View source Reliance on unrealistic self-referral for people requiring mental health and substance misuse support View source Failure to align Street Triage Team capacity with current demand View source See 8 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
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee.
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all .
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS . This may, in part, be explained by the policy/service level agreement confusion within 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis . Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition . In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances. Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation . They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy , rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police training on communicating s.136 detention decisions and reasons
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee . Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an out-of-hours local protocol for police access to mental health advice
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017.
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns. I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017.
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours , and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on unrealistic self-referral for people requiring mental health and substance misuse support
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition. In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances . Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to align Street Triage Team capacity with current demand
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017 .
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns . I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017 .
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours, and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” Open source report
Concerns raised 1 Lack of shared understanding of applicable local policy and working standards for s.136 detention View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER died on 3 July 2022 after deteriorating during a period of restraint following detention under section 136 of the Mental Health Act, with cocaine and other substances also identified in the stated cause of death. The report raises concern that the police and ambulance service did not share an understanding of the applicable local policy and working standards for managing section 136 incidents, creating a potential risk of preventable future deaths.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding of applicable local policy and working standards for s.136 detention
Wider context from the report “Confusion over applicable local policy and working standards for dealing with s.136 detention
I am concerned that there is a lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention.
At the outset of this investigation, a direction was given for disclosure of “Local memoranda or policies concerning how EMAS and Notts police jointly manage health incidents”. In response to that direction, a number of policies were disclosed, including a document entitled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedures”. Various versions of this policy were disclosed to the coroner, including a 2018, 2021 and 2024 version.
During the course of the inquest so far, I heard evidence from both the police and the ambulance service in relation to the local policy for managing s.136 incidents. The police and the ambulance service do not share an understanding of which policy they are expected to adhere to and whether there is a joint local policy. The police consider that the document above (as amended) is the applicable framework, whilst EMAS are currently unable to tell me if this policy has agreed to by them, notwithstanding that they appear as one of the agencies that formed part of the working group for each version of the MOU. The witness who gave policy evidence on behalf of EMAS told me that they only work to their own internal local standard, which is different to that in the MOU.
Persons detained under s.136 of the Mental Health Act 1983 are some of the most vulnerable in society. Their liberty has been removed, and they are reliant upon state agencies to protect their right to life. I am extremely concerned that there is no joined up thinking, or understanding, between the police and the ambulance service as to which policy and which working standards apply when furthering the protection of that right. I am concerned that this lack of basic understanding of policy and working standards by emergency services, if it persists, poses a risk of preventable future deaths.
” 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 Conduct a retrospective audit of operational memoranda of understanding to verify governance, implementation and alignment, identify safety gaps, and inform corrective actions.
Verbatim wording from the response “EMAS is committed to continuous improvement and ensuring the highest standards of patient safety and governance. In response to the issues identified, EMAS has initiated a retrospective audit of all operational Memoranda of Understanding (MoUs) received and implemented across the organisation.” Source location 2025-0363 - Response from East Midlands Ambulance Service
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 Conduct joint fact-finding with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust to clarify existing protocols and identify understanding gaps.
Verbatim wording from the response “EMAS will initiate a joint fact-finding exercise with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust (NHCHT) to clarify existing protocols and identify gaps in understanding.” Source location 2025-0363 - Response from East Midlands Ambulance Service
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 Lead development of a refreshed joint EMAS conveyance protocol, with consultation and sign-off by regional system partners.
Verbatim wording from the response “EMAS will lead the development of a refreshed joint EMAS conveyance protocol, ensuring full consultation and sign-off by all system partners within the EMAS region.” Source location 2025-0363 - Response from East Midlands Ambulance Service
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 Improve internal and external communication of regional policies to promote consistent awareness and application among stakeholders.
Verbatim wording from the response “EMAS will improve internal and external communication regarding regional policies to ensure consistent application and awareness across all stakeholders.” Source location 2025-0363 - Response from East Midlands Ambulance Service
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 Co-lead drafting of a joint s.136 conveyance protocol with Nottinghamshire Police, incorporating input from integrated care boards and mental health trusts.
Verbatim wording from the response “EMAS and Nottinghamshire Police will co-lead the drafting of a joint s.136 conveyance protocol, with input from system partners including Integrated Care Boards (ICBs) and Mental Health Trusts.” Source location 2025-0363 - Response from East Midlands Ambulance Service
Open published response
Concerns raised 4 Failure to communicate changes in discharge timings to the ambulance service View source Failure to discharge patients within the required timing when they are unable to manage independently at home View source Failure to ensure factual accuracy in Serious Incident Review reports View source Delays in completing Serious Incident Reviews View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Howe · 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 Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in discharge timings to the ambulance service
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discharge patients within the required timing when they are unable to manage independently at home
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening . In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure factual accuracy in Serious Incident Review reports
Wider context from the report “(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies , giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing Serious Incident Reviews
Wider context from the report “(2) Completion of the Serious Incident Review was delayed , and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ward contact before evening discharges will safeguard patients until the hospital’s discharge policy is received.
Verbatim wording from the response “During the Inquest, it was ascertained that discharges for patients on the wards at Manchester Royal Infirmary now have a cut off time at 21.00 hours for discharge from a hospital ward. At the time of the Inquest EMAS was not aware of this. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue to act as a safeguard to patients until the policy is received from Manchester Royal Infirmary.” Source location Response from EMAS
Open published response
24 Jun 2024 Liam Paul McCarlie · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Failure to provide EOC mental health professionals with access to relevant community mental health records 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
Liam Paul McCarlie · 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
Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide EOC mental health professionals with access to relevant community mental health records
Wider context from the report “I was told that there was no technical reason why EMAS staff (especially the mental health nurse located in the EOS) could not access a patient’s mental health records if held on SystmOne. There are such technical reasons why EMAS staff do not have access to RiO (an entirely different database). A data sharing agreement is likely to be needed as may a particular patient’s consent.
I am concerned that notwithstanding the recognition of the desirability for specialist mental health input, those mental health professionals within the EOC do not presently have access to records which may have been produced by the community mental health team . That is notwithstanding that the principal database used by the provider of community mental health treatment in Northamptonshire (the Northamptonshire Healthcare NHS Foundation Trust) is one to which EMAS does presently have access . Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources.
” Open source report
9 Jun 2023 Alice Jean FOX · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Delays in obtaining blood results needed to confirm suspected infection View source Lack of protocols ensuring safe and appropriate multi-party discharge arrangements View source Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival View source Lack of close checks and observations for patients in the hospital discharge lounge View source Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital View source Failure to respond appropriately to suspected infection when NEWS scores are low View source See 3 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
Alice Jean FOX · 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
Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining blood results needed to confirm suspected infection
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results . On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later . There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of close checks and observations for patients in the hospital discharge lounge
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care . She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments . Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately to suspected infection when NEWS scores are low
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” Open source report
14 Jan 2022 Alfie Stone · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 6 Failure to accept recommendations to carry and administer buccal midazolam when necessary View source Failure to ask parents whether the child had vomited View source Lack of paramedic training in the use of buccal midazolam View source Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations View source Failure to attempt alternative oxygenation View source Failure to attempt suction View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie 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
Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accept recommendations to carry and administer buccal midazolam when necessary
Wider context from the report “(5) East Midlands Ambulance Service were not accepting the recommendations 3 within the report to carry and administer Buccal Midazolam when necessary .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask parents whether the child had vomited
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic training in the use of buccal midazolam
Wider context from the report “(1) Apparent lack of training of paramedics in the use of Buccal Midazolam
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
Wider context from the report “(4) No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt alternative oxygenation
Wider context from the report “(2) No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt suction
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited.
” 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 and present a business case for moving to buccal midazolam, using gathered data and liaison with other ambulance trusts.
Verbatim wording from the response “As in point 1 above, EMAS provides rectal diazepam (and intravenous diazepam) for the treatment of convulsions and both are recognised treatments within the UK ambulance service clinical practice guidelines, developed by JRCALC, and within NICE guidance. Due to the discontinuation of diazepam rectal tubes 2.5mg, EMAS made a recommendation at its Medicines Governance Group in November 2021 to gather data and build a business case regarding a move to buccal midazolam, liaising with other Ambulance Trusts.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
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 Begin the governance and legal process for transitioning from the current anticonvulsant medication to buccal midazolam.
Verbatim wording from the response “Buccal Midazolam is on the agenda for the February Medicines Management Group, which is attended by senior Medical, Pharmacy and Quality leads. The intended timeline will be to start the process in April 2022, on the transition from our current anti-convulsant medication to Buccal Midazolam along with the legal processes we need to adopt to carry out this transition within the legal frameworks for this medication. The HM Coroner will be kept updated throughout this process.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a clinical bulletin reinforcing systematic seizure management, aspiration assessment and maintenance of oxygenation during patient transfer.
Verbatim wording from the response “In order to transport Alfie from his room down the stairs to the ambulance it would be technically challenging to ensure safe transfer and continual bagging of Alfie. EMAS accepts that it would have been beneficial to have maintained oxygenation via face mask during transfer to the ambulance from his bedroom. Following the outcome of this inquest, EMAS is keen to learn and embed lessons to ensure that all clinicians are reminded of the need to maintain oxygenation during the transfer of patients that are fitting. This will be covered in the bulletin stated below under question 3. To address seizure management, the HM Coroner will be provided with a copy of this bulletin when issued to our frontline staff.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
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 Add permission to administer buccal midazolam to the Scope of Practice Policy for paramedic staff.
Verbatim wording from the response “this (where family/carer are unable to do so) according to JRCALC buccal midazolam guidance. This is a recent addition to EMAS JRCALC guidance which is available to EMAS staff to access as an ‘App’ on their phone, iPad or other electronic device. It is to be added to the EMAS Scope of Practice Policy to ensure clarity for paramedic staff that they can administer within EMAS guidance.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an action plan covering training for staff who access or administer buccal midazolam, including patient-held medication.
Verbatim wording from the response “The Medicines Governance Group will develop an action plan that will consider training for all staff who would access and administer buccal midazolam in an emergency, as well as staff who may need to access and administer buccal midazolam not supplied by EMAS but held at the patient’s home or other facility.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
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 Assess the impact of adding buccal midazolam to the medicines formulary, including effectiveness, access, storage and alternative treatments.
Verbatim wording from the response “Following a review of the concerns raised in the PFD notice received on 19 January 2022, the concerns relating specifically to midazolam will be discussed at the Medicines Governance Group in February 2022 to assess the impact of adding buccal midazolam to the EMAS medicines formulary. The impact will consider treatment effectiveness, timely access to midazolam on Trust ambulances as it will need to be securely stored in a cabinet only accessible by controlled key access and it may take longer to access in an emergency (due to this being a Schedule 3 controlled drug within the Misuse of Drugs Regulations 2001) and alternative treatments.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Suction was not required because the child did not vomit while the crew was present.
Verbatim wording from the response “3. No suction attempted, and the question was not asked of the parents as to whether the child had vomited.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continual bagging during transfer was technically challenging because safe movement down the stairs could not be ensured.
Verbatim wording from the response “In order to transport Alfie from his room down the stairs to the ambulance it would be technically challenging to ensure safe transfer and continual bagging of Alfie. EMAS accepts that it would have been beneficial to have maintained oxygenation via face mask during transfer to the ambulance from his bedroom. Following the outcome of this inquest, EMAS is keen to learn and embed lessons to ensure that all clinicians are reminded of the need to maintain oxygenation during the transfer of patients that are fitting. This will be covered in the bulletin stated below under question 3. To address seizure management, the HM Coroner will be provided with a copy of this bulletin when issued to our frontline staff.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No audit of buccal midazolam training was required because it was not in the medicines formulary at the time.
Verbatim wording from the response “Recommendation 3 of the Kettering report states: “EMAS should audit training and competencies of first responders in administration of buccal midazolam in children experiencing prolonged seizures in line with Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance”.” Source location 2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
Open published response
21 May 2021 Morris REDDINGTON · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to review the electronic Patient Report Form during emergency department handover View source Failure to resolve electronic Patient Report Form access problems View source Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke 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
Morris REDDINGTON · 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
Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review the electronic Patient Report Form during emergency department handover
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form . The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone .
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution.
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre.
Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve electronic Patient Report Form access problems
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone.
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution .
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre .
Whilst ever this problem persists without resolution , there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke
Wider context from the report “In January 2018, NHS England published its Clinical Commissioning Policy on the use of Mechanical Thrombectomy as treatment for acute ischaemic stroke (all ages).
The aim of the Policy reports to be two-fold; to improve outcomes for adults with stroke, and to improve access to mechanical thrombectomy as soon as possible after the onset of stroke symptoms.
Despite the publication of the policy some 3 years ago, there remains very limited access to 24/7 mechanical thrombectomy . Save for two Trusts in London, and the West Midlands Network, I am not aware of others providing a 24/7 service. There certainly is no such service in the East Midlands .
There is clear geographical disparity in the access to this vital, life-saving service .
Mechanical thrombectomy would likely have avoided Mr Reddington’s death. Instead, because Mr Reddington was unfortunate enough to suffer a stroke outside of the service’s operational hours (Monday to Friday 8am to 4pm), his family were left to watch his deterioration, knowing that a treatment had the potential to save his life, but that such treatment simply was not offered after 4pm .
This is a situation that no family ought to be placed in.
” Open source report
4 Feb 2020 Mr Gordon Gillott · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Unavailability of urgent transfers for acutely ill patients due to resourcing issues View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Gordon Gillott · 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
Mr Gordon Gillott presented with a ruptured abdominal aneurysm, underwent surgery, and later died from sepsis secondary to a bowel perforation. The principal concern was a substantial ambulance delay in transferring him, caused by resourcing issues, creating a risk of future deaths among acutely ill patients requiring urgent transfers.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of urgent transfers for acutely ill patients due to resourcing issues
Wider context from the report “1. Whilst this delay did not affect Mr Gillott, were this to happen again in the future, there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues .
” 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 Prepare vehicles to increase availability for clinical response.
Verbatim wording from the response “• Make ready to increase vehicle availability for clinical response” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Offer incentives to attract staff during the busy winter period.
Verbatim wording from the response “• Offering incentives to attract staff over busy winter period” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 acute partners to implement protocols, including rapid handover, that free crews for appropriate activity.
Verbatim wording from the response “External Efficiencies (external)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Increase hear-and-treat activity, including for mental-health calls.
Verbatim wording from the response “• Increasing hear and treat (e.g. MH calls)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Use capacity management to target limited resources at the most clinically urgent calls.
Verbatim wording from the response “• Capacity management to ensure limited resource targeted at most clinically urgent (CAT) (C2)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Deploy the Clinical Assessment Team for patients unlikely to require conveyance.
Verbatim wording from the response “• Clinical Assessment Team (CAT) for patients unlikely to be suitable for conveyance” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Manage sickness and other staff abstractions robustly to protect operational capacity.
Verbatim wording from the response “• Robustly managing sickness and other abstractions” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Make welfare calls and reprioritise cases when performance targets are not met, with further clinical assessment or escalation where appropriate.
Verbatim wording from the response “• Welfare calls and re-prioritisation where performance targets not met. Referral to CAT for further assessment/escalation as appropriate including PSIS/JS/ICS? /RTA? /AOC/OTs” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Operate the winter concept of operations to manage seasonal operational pressure.
Verbatim wording from the response “• Winter concept of operations (winter plan)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Operate 24-hour tactical cells in each division to monitor job-cycle activity and intervene to improve efficiency, including before handover.
Verbatim wording from the response “• T/C cells in operation 24/7 in each division to monitor in real time job cycle activity and intervene as appropriate to promote efficiency including pre-handover.” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Cancel scheduled non-essential training programmes during periods of operational pressure.
Verbatim wording from the response “• Cancellation of non-essential training programmes scheduled” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Recruit 274 whole-time-equivalent staff under the workforce plan and use 50 support roles to meet operational requirements.
Verbatim wording from the response “Resourcing (internal)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Implement the national Health Care Professional Admissions and Inter-Facility Transfers Framework for hospital transfers.
Verbatim wording from the response “EMAS implemented the new national Health Care Professional Admissions and Inter-Facility Transfers Framework on the 1 October 2019. We have included the National Framework for Interfacility Transfers document for your information.” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Facilitate an internal review process for prolonged waits and escalate cases appropriately.
Verbatim wording from the response “• Internal process of CSG facilitated and review process for prolonged waits with appropriate escalation of cases where required” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Monitor transfer performance and take action to improve operational response.
Verbatim wording from the response “We continue to monitor performance and take action to improve our operational response. I have enclosed a copy of a table outlining the actions we are taking, including those that are in collaboration with system partners.” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Reduce vehicle off-road time through proactive maintenance.
Verbatim wording from the response “• Reduced vehicle off road time by proactive maintenance” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Increase call-answering efficiency by reducing travel time.
Verbatim wording from the response “• Increasing call answering efficiency by reducing travel time (made)” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
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 Provide managerial presence in emergency departments to support crews with handover.
Verbatim wording from the response “• Managerial presence in EDs to support crews around handover” Source location 2020-0020-Response-from-East-Midlands-Ambulance-Service
Open published response
19 Nov 2019 Helen BARKER · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 2 Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded View source Failure to ensure CAT Team Leader contact with NHS 111 for increasing unassessed category 3 calls passed to the Trust 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
Helen BARKER · 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 BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded
Wider context from the report “1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:-
Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust.
Has this recommendation now been implemented particularly where attempted suicides have been reported.
Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded?
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure CAT Team Leader contact with NHS 111 for increasing unassessed category 3 calls passed to the Trust
Wider context from the report “1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:-
Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust.
Has this recommendation now been implemented particularly where attempted suicides have been reported.
Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded?
” Open source report
Concerns raised 1 Failure to dispatch an ambulance to the correct patient address View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Thomas Trevor BEAN · 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
Ian Thomas Trevor Bean died at Liskeard in Cornwall after taking an overdose of prescribed morphine, and the inquest recorded multidrug toxicity and chronic obstructive pulmonary disease, with suicide as the conclusion. An ambulance was mistakenly dispatched to his father’s address in Nottingham rather than to Mr Bean in Cornwall; although this was accepted at inquest not to have caused the death, it was identified as a fundamental error requiring attention to prevent similar oversights.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to dispatch an ambulance to the correct patient address
Wider context from the report “An ambulance was wrongly dispatched to the address of Mr Bean’s father in Nottingham rather than to Mr Bean in Cornwall.
” 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 electronic call-passing that limits gateway address entry and records any additional address separately on the incident file.
Verbatim wording from the response “We continually review our systems and processes to ensure that we are delivering the best possible service to our patients. We have worked with other Ambulance Trusts to develop call-passing technology. Since 13 December 2018, calls are passed through an electronic gateway, which negates the need for verbal handover.” Source location 2019-0340-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
Concerns raised 3 Failure to provide senior review or red-flag warnings of heightened concern to attending crews View source Lack of capacity to link repeat emergency calls concerning the same patient at the same address View source Lack of a system for using linked repeat-call information to provide patient safety-netting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Graham George Smith · 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
Graham George Smith died in a house fire at his home on 24 April 2018, after deteriorating during alcohol and benzodiazepine withdrawal and refusing hospital transport on three occasions. The report raised concerns that emergency call handling could not link repeat calls about the same patient and address, and that attending ambulance crews lacked information, senior review and warning of heightened concern.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide senior review or red-flag warnings of heightened concern to attending crews
Wider context from the report “It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews . The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed.
It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity to link repeat emergency calls concerning the same patient at the same address
Wider context from the report “It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time . As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed.
It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for using linked repeat-call information to provide patient safety-netting
Wider context from the report “It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting . There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed.
It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED.
” 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 Extend duplicate-call alert checking toward a 12-hour window while reviewing CAD feasibility and system-performance impact.
Verbatim wording from the response “EMAS currently has a process in place to alert all Emergency Operations Centre (EOC) staff upon receipt of a call, that a previous call has been made from that same address, or within 50 meters of the address coordinates, within the last nine hours. This is highlighted by a yellow warning box stating “Possible Duplicate Calls” on the Computer Aided Dispatch (CAD) system.” Source location 2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Provide the clinical advice team with access to previous calls, attendances, summary care records and Leicester SystmOne records to inform referral and safe-discharge decisions.
Verbatim wording from the response “Refusal to travel – If a patient refuses transport to hospital; the attending Technician should carry out a mental capacity assessment on the patient and then contact the CAT who will speak to the patient and ensure that the refusal is made on a recorded telephone line. The patient’s signature should be gained on the Electronic Patient Report Form stating that they are refusing transport to hospital, as per the Non-Conveyance Summary Guide for Technicians.” Source location 2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Extending duplicate-call checking requires assurance that increased CAD processing will not detrimentally affect the system’s ability to handle incoming calls.
Verbatim wording from the response “Having received this notification, the dispatcher will check the CAD system and verbally notify the crew by radio of any previous attendance within the last nine hours. In Mr Smith’s case, however, the previous attendance was outside of this window, which at that time was only five hours. We are incrementally increasing this time to twelve hours; however we have to do this in small increments to ensure that it does not have a detrimental impact on the CAD system.” Source location 2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Existing CAT access to prior attendances, summary care records and local GP records enables informed onward-referral or safe-at-home decisions.
Verbatim wording from the response “The CAT team has had access to all previous calls and attendances for the past three months. The team also has access to summary care records (which are an electronic record of important patient information, created from GP medical records) and in Leicester, read-only access to SystmOne (a centrally hosted clinical computer system used by GPs and other healthcare professionals in the UK). This enables the CAT clinician to be fully informed of the patient’s past medical history and any care plans which may be in place, enabling them to make an informed decision as to whether the patient requires onward referral or whether the patient can safely be left at home.” Source location 2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
24 Jan 2019 Olive JOHNSON · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 4 Insufficient conveying resources to meet response targets View source Failure to include time from the initial call to regrading in response-time measurement View source Failure to meet response times View source Failure to call out first responders View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olive JOHNSON · 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
Olive JOHNSON died within 24 hours of admission to Pilgrim Hospital on 11 May 2018. The concerns raised relate to the absence of a first responder, emergency response times, how response delays were recorded after regrading, and whether EMAS had sufficient conveying resources to meet its targets.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient conveying resources to meet response targets
Wider context from the report “d) Do EMAS believe they have enough conveying resources to meet their response targets ?
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include time from the initial call to regrading in response-time measurement
Wider context from the report “c) Is it fair that if a patient is regarded whilst awaiting an initial response the total time from the initial call to the regrading is cancelled out ?
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meet response times
Wider context from the report “b) How many occasions have EMAS exceeded their response times since 01/01/2108 to date?
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to call out first responders
Wider context from the report “a) Why were no first responder's called out in relation to the deceased?
” 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 Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.
Verbatim wording from the response “In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.” Source location 2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.
Verbatim wording from the response “In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.” Source location 2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 available Community First Responder could not attend because excessive travel distance fell outside the role’s intended community coverage.
Verbatim wording from the response “a) Why were no First Responders called out in relation to the deceased?” Source location 2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 response clock for re-categorised calls starts at regrading because this timing was decided from a national perspective.
Verbatim wording from the response “c) Is it fair that if a patient is regraded whilst awaiting an initial response, the total time from the initial call to the regrading is cancelled out?” Source location 2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
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.
×
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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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
×
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 Recruit private providers with qualified staff to support the additional ambulance response resources.
Verbatim wording from the response “the process of being recruited. 20 staff are now recruited, trained and operational. The remainder in training will commence training in the next quarter. To support the additional resources, we are also recruiting private providers with qualified staff.” Source location 2019-0015-Response-by-East-Midlands-Ambulance-Service
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 Agree contract terms providing additional funding for clinical staff, ambulances and other response resources.
Verbatim wording from the response “In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m extra funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.” Source location 2019-0015-Response-by-East-Midlands-Ambulance-Service
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 Expand Northamptonshire frontline staffing, including recruitment, training and operational deployment of additional staff.
Verbatim wording from the response “Since the additional funding was announced and as at the end of February 2019, the Northamptonshire Division have recruited an extra 39 frontline staff and further staff are in” Source location 2019-0015-Response-by-East-Midlands-Ambulance-Service
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 Capacity Management and Escalation Plan’s existing triggers are considered safe for managing demand and are reviewed annually.
Verbatim wording from the response “We do look to move resources from one Division to another and therefore we have to balance against how many jobs are holding in each Division. On this occasion, it was unfortunately not possible to move any resources.” Source location 2019-0015-Response-by-East-Midlands-Ambulance-Service
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 information provided did not warrant escalation, so the call was appropriately categorised without a higher-priority response.
Verbatim wording from the response “Each individual call received by the Trust is either triaged via the Advanced Medical Priority Dispatch System (AMPDS), using the information provided to us either by the caller or is received via the electronic gateway from NHS Pathways - the 111 system. The AMPDS is an internationally recognised triage system that uses a data set to determine the response level required, based on the information provided during the call.” Source location 2019-0015-Response-by-East-Midlands-Ambulance-Service
Open published response
8 Mar 2018 BERNARD LESLIE GERRARD · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Delays in emergency vehicle responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BERNARD LESLIE GERRARD · 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
Bernard Leslie Gerrard sustained injuries in an unwitnessed fall at the care home, was found to have a left fractured neck of femur, and died on 2 December 2017 despite treatment. The principal concern was a prolonged ambulance response, including delays to both the initial Category 3 response and the later Category 2 response, which EMAS attributed to insufficient resources and funding.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency vehicle responses
Wider context from the report “(1) There was a 10 hour vehicle response delay to attend to a Category 3 call. When the call was eventually upgraded to a Category 2 response, there was a further 50 minute delay . EMAS report that they cannot cope with the current demands placed on their service due to insufficient funding which is resulting in unacceptable vehicle response times
” 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 Establish and operate an Urgent Care Transport Service with dedicated crews and dispatch arrangements for urgent and low-acuity patients.
Verbatim wording from the response “As part of this review the Trust has already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April. We operate 25 crews on duty across the region responding to patients who either require urgent admission to hospital, as determined by their general practitioner or other healthcare professional (HCP), or who have low acuity healthcare needs as assessed by our Clinical Assessment Team or frontline emergency crews.” Source location 2018-0070-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Implement the outcome of the strategic demand and capacity review.
Verbatim wording from the response “East Midlands Ambulance Service (EMAS) does not believe it is funded correctly to deliver the service our patients require. As a result the EMAS 2016/17, Urgent and Emergency Ambulance Contract, documented the agreement made between the Commissioners and ourselves to undertake a jointly commissioned Independent Strategic Demand and Capacity Review, to understand the number of staff we require to deliver the nationally agreed standards. Within that agreement EMAS formally committed to the implementation of the outcome of the review, while Commissioners formally committed to support the implementation of the outcome.” Source location 2018-0070-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Complete the jointly commissioned strategic demand and capacity review to determine staffing requirements against national performance standards.
Verbatim wording from the response “East Midlands Ambulance Service (EMAS) does not believe it is funded correctly to deliver the service our patients require. As a result the EMAS 2016/17, Urgent and Emergency Ambulance Contract, documented the agreement made between the Commissioners and ourselves to undertake a jointly commissioned Independent Strategic Demand and Capacity Review, to understand the number of staff we require to deliver the nationally agreed standards. Within that agreement EMAS formally committed to the implementation of the outcome of the review, while Commissioners formally committed to support the implementation of the outcome.” Source location 2018-0070-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Recruit and train approximately 295 frontline operational staff and 48 Emergency Operations Centre staff for operational deployment during 2018/19 and early 2019/20.
Verbatim wording from the response “Due to the implementation of the national standards following the introduction of the Ambulance Response Programme in July 2017, the review concluded at the end of March. The review has confirmed that EMAS has a substantial resource gap and requires approximately 295 additional frontline operational staff and 48 additional staff to work within the Emergency Operations Centre to enable us to deliver the nationally defined performance standards.” Source location 2018-0070-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Insufficient funding and a substantial resource gap prevent delivery of nationally defined ambulance performance standards.
Verbatim wording from the response “East Midlands Ambulance Service (EMAS) does not believe it is funded correctly to deliver the service our patients require. As a result the EMAS 2016/17, Urgent and Emergency Ambulance Contract, documented the agreement made between the Commissioners and ourselves to undertake a jointly commissioned Independent Strategic Demand and Capacity Review, to understand the number of staff we require to deliver the nationally agreed standards. Within that agreement EMAS formally committed to the implementation of the outcome of the review, while Commissioners formally committed to support the implementation of the outcome.” Source location 2018-0070-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
1 Mar 2018 George French Russell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to seek guidance during rapidly evolving labour situations View source Lack of structured and direct information sharing between hospital and ambulance services View source Lack of paramedic experience in managing footling breech deliveries View source Failure to provide or seek continuing expert support during footling breech deliveries View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George French Russell · 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
George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek guidance during rapidly evolving labour situations
Wider context from the report “1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route. (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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured and direct information sharing between hospital and ambulance services
Wider context from the report “2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3rd hand .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic experience in managing footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery . Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or seek continuing expert support during footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought .
” 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 the SBAR communication framework for clinical handovers.
Verbatim wording from the response “Point Two:
EMAS recognises the importance of good communication and information sharing in relation to the delivery of high quality care and patient safety. As such EMAS will now implement a communication framework to ensure the provision of good quality clinical handovers, the SBAR model. The SBAR model (standing for: Situation, Background, Assessment, Recommendation) is a structured communication tool that is considered a best practice element in healthcare settings and has been” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Remind clinical staff to escalate advice-call failings so appropriate advice and support are obtained.
Verbatim wording from the response “With specific regard to the call contact being prematurely ceased, all clinical staff have been reminded of the importance of escalating advice call failings to ensure appropriate advice and support is obtained .” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Implement standardised minimum criteria for requesting remote or on-scene obstetric support.
Verbatim wording from the response “To ensure a more timely and objective Trust approach to community obstetric support EMAS has developed a standardised minimum criteria for requesting support from a remote service and from an on scene clinician. This is expected to be implemented in May 2018 subjected to governance processes. As an interim measure, guidance has been issued by clinical bulletin and to all relevant EOC staff.” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and seek regional agreement for a maternity-specific SBAR handover model.
Verbatim wording from the response “With regards to the specific concerns identified by HM Coroner’s inquest we are also working with our obstetric service partners to extend the SBAR to create a maternity specific model. This approach has been formally shared with our network partners through the East Midlands Maternity Clinical Advisory Group following a debate in early March 2018, in draft format for agreement as a standardised regional handover tool. This is planned for implementation across the EMAS footprint in May 2018 subject to governance approval.” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop standardised minimum criteria for requesting remote or on-scene obstetric support.
Verbatim wording from the response “To ensure a more timely and objective Trust approach to community obstetric support EMAS has developed a standardised minimum criteria for requesting support from a remote service and from an on scene clinician. This is expected to be implemented in May 2018 subjected to governance processes. As an interim measure, guidance has been issued by clinical bulletin and to all relevant EOC staff.” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Implement the maternity-specific SBAR handover model across the EMAS footprint.
Verbatim wording from the response “With regards to the specific concerns identified by HM Coroner’s inquest we are also working with our obstetric service partners to extend the SBAR to create a maternity specific model. This approach has been formally shared with our network partners through the East Midlands Maternity Clinical Advisory Group following a debate in early March 2018, in draft format for agreement as a standardised regional handover tool. This is planned for implementation across the EMAS footprint in May 2018 subject to governance approval.” Source location 2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
31 Jan 2017 Dipa Rameshchandra Lad · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Lack of clarity and consistency in the diagnosis-of-death procedure View source Lack of verification that staff have read and understood protocol changes View source Lack of guidance for determining when resuscitation is futile View source Unavailability of a reference guide reflecting local diagnosis-of-death policies View source Lack of training on the protocol change View source Failure to ensure staff awareness of changes to resuscitation policy View source Failure to use effective chest-compression technique View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dipa Rameshchandra Lad · 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
Dipa Lad died after using an item of clothing to ligate on 4 March 2016; the medical cause of death was ligature pressure to the neck. The principal concerns related to differences between national guidance and the local ambulance protocol for stopping resuscitation, including the lack of guidance on when resuscitation was futile, staff awareness and training, and the clarity of the procedure. A further concern related to the technique used by one technician when giving chest compressions.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and consistency in the diagnosis-of-death procedure
Wider context from the report “6. I do not consider the current EMAS ‘Diagnosis of Death Procedure’ to be sufficiently clear / consistent (particularly when comparing the wording and the flow - charts) . This also contains no guidance on when resuscitation should be considered ‘futile’, as referred to 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of verification that staff have read and understood protocol changes
Wider context from the report “4. We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these , and there has been no training on this change.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for determining when resuscitation is futile
Wider context from the report “2. The distinction between national guidance and local protocol is that EMAS crews may deem a resuscitation effort to be ‘futile’. This is a clear and important deviation from national guidance, yet staff have been given no guidance about what a ‘futile’ resuscitation is . Whilst this may be clear in some situations, the protocol, if adopted, should give guidance where a situation is less clear – and perhaps consider providing that where there is any doubt, that full ALS protocol should be applied. As it currently stands, the protocol places a large burden on staff to ascertain ‘futility’ with no guidance whatsoever .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a reference guide reflecting local diagnosis-of-death policies
Wider context from the report “5. We heard that staff carry JRCALC pocketbooks as reference guides. EMAS policy around diagnosis of death differs in a key respect from JRCALC guidelines – but there is no equivalent pocketbook / amendment to existing pocketbook / similar which reflects local policies .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on the protocol change
Wider context from the report “4. We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness of changes to resuscitation policy
Wider context from the report “3. It was clear that most of the staff attending this emergency were not aware of the change in local policy . On arrival of the team leader (who told us she was aware of the protocol), resuscitation efforts were stopped. I am concerned about the clear disparities in awareness of this important change to protocol .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use effective chest-compression technique
Wider context from the report “7. One of the technicians who attended gave chest compressions standing up – with both feet on the same side of the patient . The reason she gave for this was not wanting to get blood from the scene on her trousers. She was not in a confined space, and when challenged by her team leader subsequently, used a towel to protect her clothes and continued to give compressions kneeling down. I am concerned to ensure that staff are trained / reminded of the best technique to give effective compressions – for the patient and for staff resilience reasons.
” 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 Revise and approve the Diagnosis of Death Procedure to clarify wording, align flowcharts, and provide guidance on recognising futile resuscitation.
Verbatim wording from the response “Although the procedure was based upon national guidance and was deemed to be safe following this inquest the current EMAS Diagnosis of Death Procedure has been reviewed again against the national guidance. The revised version has been approved within EMAS and I have attached a copy for your reference.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Issue the updated action cards to all ambulance clinicians.
Verbatim wording from the response “To support clinicians and assist clinicians with recognising when resuscitation may be futile, an action card has been updated to include the relevant parts of the update of the Diagnosis of Death Procedure which assists with identifying the key features if managing a cardiac arrest with appropriate management plans. This will include the guidance around ‘futility’ and when resuscitation should not be commenced/continued. The action cards will be issued to all ambulance clinicians to support them within their role.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Update the clinician action card with Diagnosis of Death Procedure guidance on futility and when resuscitation should not be commenced or continued.
Verbatim wording from the response “To support clinicians and assist clinicians with recognising when resuscitation may be futile, an action card has been updated to include the relevant parts of the update of the Diagnosis of Death Procedure which assists with identifying the key features if managing a cardiac arrest with appropriate management plans. This will include the guidance around ‘futility’ and when resuscitation should not be commenced/continued. The action cards will be issued to all ambulance clinicians to support them within their role.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Introduce a clinical-information dissemination procedure using risk-based bulletins with mandatory receipt and understanding confirmation for critical updates, supported by weekly monitoring.
Verbatim wording from the response “To ensure that key information around changes to clinical practice are disseminated to clinical staff in July 2016 EMAS introduced a revised version of the Procedure for the Dissemination of Clinical Information to Clinical Staff Members.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Diagnosis of Death Procedure was based on national guidance and was deemed safe, although it was subsequently reviewed and revised.
Verbatim wording from the response “The development of the EMAS Diagnosis of Death Procedure has been reviewed and the procedure was developed around and is based upon current national guidance. Decisions Relating to Cardiopulmonary Resuscitation was a guidance document issued from the British Medical Association (BMA), the Resuscitation Council (UK) (RCUK) and the Royal College of Nursing (RCN) and was used when developing the procedure. The 3rd edition (1st revision) was published in 2016 and a copy has been included with our response letter. During the development of the procedure it was sent out for consultation to a wide range of stakeholders including HM Coroners across the East Midlands region and any feedback received was incorporated into the document. Following the amendments, the procedure was approved through the normal EMAS governance procedures.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
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 Existing training and annual resuscitation refreshers, alongside dynamic risk assessment, are considered sufficient for effective chest compressions despite technique varying by circumstances.
Verbatim wording from the response “Although the most appropriate technique to perform CPR is to be kneeling close to the patient or standing over the patient this cannot always be possible and staff will conduct their own dynamic risk assessment when performing chest compressions. All clinical staff are trained in delivering effective chest compressions and undergo an annual statutory and mandatory refresher training course which includes updates and an assessment on resuscitation in one of our education centres.” Source location 2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Open published response
26 May 2016 Peter Scott · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Insufficient ambulance service resources and staffing capacity View source Delays in hospital handover of ambulance patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Scott · 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 Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.
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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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service resources and staffing capacity
Wider context from the report “I remain very concerned about resource issues for this ambulance service . I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months .
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send . Demand is clearly greater than the resources they have most of the time , given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service . We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals. I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals . I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” 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 Produce a People Strategy to develop and support highly skilled, motivated, caring and compassionate staff.
Verbatim wording from the response “To address this, EMAS has produced a new People Strategy to develop and support our staff to be highly skilled, motivated, caring and compassionate professionals.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue escalating hospital handover delays and working with regulators, commissioners, hospitals and the wider health and social care system to improve them.
Verbatim wording from the response “That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Maintain daily contact and joint working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays.
Verbatim wording from the response “• Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Recruit and educate 350 whole-time-equivalent frontline staff against the recruitment plan.
Verbatim wording from the response “Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against a recruitment plan target of 342. However, a higher level of turnover was experienced compared to that forecast (11% against a target of 8%). EMAS continues to recruit to the frontline again this year.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Reintroduce monthly meetings with QMC and commissioners to identify improvements to ambulance turnaround times.
Verbatim wording from the response “The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting frontline staff during 2016/17.
Verbatim wording from the response “Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against a recruitment plan target of 342. However, a higher level of turnover was experienced compared to that forecast (11% against a target of 8%). EMAS continues to recruit to the frontline again this year.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Implement the outcomes of the independent strategic demand, capacity and price review.
Verbatim wording from the response “A key part of this year’s contract is the agreement to carry out an independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service. EMAS and the clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Introduce a booking system with priority patient assessment during hospital delays.
Verbatim wording from the response “• A new booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when delays are being experienced” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Install ambulance arrival screens at QMC to provide real-time handover data and identify delays.
Verbatim wording from the response “Since March 2016 the QMC has engaged with EMAS to install Ambulance arrival screens. Unlike RFID which used electronic tags the ambulance arrivals screen uses a simple touchscreen interface based on a webpage. This new process provides real time data to both QMC and EMAS which allows both to see delays as they happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete. The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Increase the number of paramedics based at hospitals to support patient triage and departmental flow.
Verbatim wording from the response “• Increased number of paramedics based at hospitals to support their teams with the triage of patients and flow through the department” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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 Increase available DCA and FRV hours through staff recruitment and roster realignment to match increased demand.
Verbatim wording from the response “Since April 2015 Nottinghamshire Division has increased the available hours for both Double Crewed Ambulance (DCA) and solo Fast Response Vehicles (FRV). This is through the recruitment of staff and realignment of rosters to match increased demand.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an independent strategic review of staffing, vehicle and financial capacity required to meet demand.
Verbatim wording from the response “A key part of this year’s contract is the agreement to carry out an independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service. EMAS and the clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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.
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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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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 East Midlands Ambulance Service NHS Trust; 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
Concerns raised 6 Failure to provide robust, effective and event-responsive complex case planning View source Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes View source Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records View source Failure to formalise multidisciplinary team meetings View source Failure to investigate suspected overdose events and apply learning outcomes View source Under-utilisation of enhanced case management for complex prisoners View source See 3 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
Ahmedreza Fathi · 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
Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.
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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust, effective and event-responsive complex case planning
Wider context from the report “1. Healthcare complex case planning was not robust or effective , and was not reviewed or updated in response to subsequent events . Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions . Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison .
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise multidisciplinary team meetings
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected overdose events and apply learning outcomes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes . This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Under-utilisation of enhanced case management for complex prisoners
Wider context from the report “2. The enhanced case management system referred to in PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations