18 Mar 2026 Edna May Wiggett · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Failure to re-triage and re-classify cases when subsequent relevant information is received 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
Edna May Wiggett · 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
Edna May Wiggett fell at home and sustained a fractured hip, underwent surgery, and later died from heart failure following surgery. The report identified a failure to re-triage a second ambulance call reporting increased pain, leading to delays in dispatch and a prolonged wait on the floor, which more than minimally contributed to her death.
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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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to re-triage and re-classify cases when subsequent relevant information is received
Wider context from the report “(1) the failure to re-triage Mrs. Wiggett’s case and consider a re-classification following receipt of a second call providing relevant information (an increase in pain) leading to delays in the dispatch of an ambulance .
” 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 Publish a Patient Safety and Experience Newsletter article reminding staff to re-triage calls when presentations change.
Verbatim wording from the response “A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.” Source location Response from East of England Ambulance 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 Discuss re-triage learning and potential themes at the Learning Group.
Verbatim wording from the response “A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.” Source location Response from East of England Ambulance 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 Re-triage at the second call was unlikely to produce a higher categorisation because pain is excluded from AMPDS triage questions.
Verbatim wording from the response “A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.” Source location Response from East of England Ambulance NHS Trust
Open published response
2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
View report summary
Concerns raised 7 Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital View source Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint View source Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage View source Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint View source Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables View source Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials View source Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Scott Darren TAYLOR · 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
Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital
Wider context from the report “b. Whilst it would not have changed the outcome for Mr Taylor, arm and leg restraints were not removed by police officers in this case when it was understood that Mr Taylor was unconscious and when Mr Taylor was being conveyed to hospital . Police officers who gave evidence were not clear that this was a requirement of the policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Wider context from the report “b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients . Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Wider context from the report “a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint
Wider context from the report “a. It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1 . This means that there is not a national standard for response Acute Behavioural Disturbance with active 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables
Wider context from the report “a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance . Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials
Wider context from the report “d. The EEAST documents continue to use the term ‘Excited Delirium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status
Wider context from the report “c. The EEAST updated training on Acute Behavioural Disturbance, active restraint and reports received from police and correct coding remains confusing with the policy and training handouts in December 2023 with discrepancies between those who are sectioned and those who are not. Persons confirmed with Acute Behavioural disturbance and in active police restraint being coded as Category 2 and those in the same circumstances and ‘sectioned’ will require a Category 1 response . The difference appears to be one related to the Mental Health Act and not the presentation or clinical requirements of the person .
” 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 Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.
Verbatim wording from the response “Following the inquest a working group was set up with the intention of revising the guidance for patients exhibiting signs of Acute Behavioural Disturbance and establishing the most appropriate way to respond to those patients within the Emergency Operations Centre.” Source location Response from East of England Ambulance Service
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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 Update, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.
Verbatim wording from the response “The procedure has also been updated to reflect that a Category 1 coding is now applied to all calls where the police are actively restraining a patient; or reporting agitation/behaviour changes; or the police use the term Acute Behavioural Disturbance. The call handler will immediately escalate this to a Call Handler Team Leader who will upgrade the call to a Category 1 and the response will be dispatched on this basis. If, at this point, the Call Handler Team Leader or Dispatcher believe this may not be a Category 1 call, the call will be highlighted to a Clinical Navigator who will complete a clinical review and triage to establish if a downgrade is required.” Source location Response from East of England Ambulance Service
Open published response
1 Feb 2024 Lucas Tyler Pollard · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 4 Unsafe application of the policy when the patient's survival cannot be known at the time of the call View source Failure to review incident management in response to evidence of deterioration during a 999 call View source Failure to undertake ongoing reassessment when applying the End Of Shift Policy View source Failure to dispatch a Critical Care Team immediately in serious incidents View source See 1 more concern
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
Lucas Tyler Pollard · 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
Lucas Tyler Pollard, aged 14, died after sustaining catastrophic injuries in a collision while riding an electric moped on 1 June 2023. Concerns included the failure to dispatch a Critical Care Team promptly, the cancellation of a rapid response vehicle three minutes from the scene under the End of Shift Policy, and the absence of dynamic reassessment despite evidence of his deterioration. The report also raised concern that applying the policy in this way could threaten a patient's life in future situations.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe application of the policy when the patient's survival cannot be known at the time of the call
Wider context from the report “(4) While the medical evidence after consideration of the clinical presentation and the post mortem examination was clear that Lucas would not have survived, at the time of the call that was not and could not be known . Application of the policy as it was, in future situations, may represent a threat to a patient's life .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review incident management in response to evidence of deterioration during a 999 call
Wider context from the report “(3) There was clear evidence from the 999 call both from the caller and the obvious deterioration of Lucas from sounds in the background but that did not prompt a review of the management of the incident by EEAST .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake ongoing reassessment when applying the End Of Shift Policy
Wider context from the report “(2) That the End Of Shift Policy was applied without evidence of an ongoing reassessment of the situation and the RRV, positioned only 3 minutes from the incident, was consequently not deployed .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to dispatch a Critical Care Team immediately in serious incidents
Wider context from the report “(1) That a Critical Care Team was not dispatched immediately given the serious nature of the call and the likely lack of clinical information for some considerable time ie waiting for the land ambulance, known to be more than 20 minutes away, to arrive and assess .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the approved End of Shift Policy with all AOC staff and include it in update training.
Verbatim wording from the response “the last 30 minutes and dispatch the nearest available resource”. Unfortunately, the escalation to the Clinical Coordinator or Senior AOC Clinician did not happen on this occasion. The End of Shift Policy is currently being reviewed in order to ensure it remains clinically appropriate for our patients’ needs but also meets our obligations in relation to staff welfare. Once the policy has been reviewed and approved, it will be shared with all AOC staff and included in any update training. We aim to complete this piece of work by the end of June 2024.” Source location Response from East of England 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 Integrate the Critical Care desk function into all three control rooms to improve identification, monitoring and reassessment of enhanced-care needs.
Verbatim wording from the response “The integration of the Critical Care desk function from a two-person team into all three control rooms will significantly enhance EEAST’s ability to identify, continually monitor and reassess need for enhanced care. We will also share a case study of our attendance to Lucas with the Critical Care Desk clinicians for awareness.” Source location Response from East of England 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 Address active listening and appropriate call escalation specifically with call handlers during supervision or one-to-one meetings.
Verbatim wording from the response “There were opportunities to escalate this call to the Clinical Coordinator or Senior AOC Clinician for further review. Active listening and escalation of calls are covered throughout the Call Handlers’ training course, with specific emphasis on the type of calls that should be escalated. An article will be published in What’s Out Wednesday, which is the weekly newsletter shared with all AOC staff across the Trust, for general awareness in order to remind staff of the importance of active listening and escalating calls where appropriate. In addition, it will be picked up specifically with the call handlers in their supervision/1:1 meetings.” Source location Response from East of England 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 Publish an article in the weekly AOC staff newsletter reminding staff to actively listen and escalate calls where appropriate.
Verbatim wording from the response “There were opportunities to escalate this call to the Clinical Coordinator or Senior AOC Clinician for further review. Active listening and escalation of calls are covered throughout the Call Handlers’ training course, with specific emphasis on the type of calls that should be escalated. An article will be published in What’s Out Wednesday, which is the weekly newsletter shared with all AOC staff across the Trust, for general awareness in order to remind staff of the importance of active listening and escalating calls where appropriate. In addition, it will be picked up specifically with the call handlers in their supervision/1:1 meetings.” Source location Response from East of England 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 Review the End of Shift Policy to ensure clinical appropriateness and alignment with staff-welfare obligations.
Verbatim wording from the response “the last 30 minutes and dispatch the nearest available resource”. Unfortunately, the escalation to the Clinical Coordinator or Senior AOC Clinician did not happen on this occasion. The End of Shift Policy is currently being reviewed in order to ensure it remains clinically appropriate for our patients’ needs but also meets our obligations in relation to staff welfare. Once the policy has been reviewed and approved, it will be shared with all AOC staff and included in any update training. We aim to complete this piece of work by the end of June 2024.” Source location Response from East of England Ambulance Service NHS Trust
Open published response
15 Jan 2024 Dennis John William KING · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Inadequacy of the action plan for addressing ambulance response concerns View source Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers View source Lack of clarity in the categorisation process for urgent inter-hospital transfers View source Inadequate means for delivering centralised exigent care through regional centres View source Unavailability of ambulances for timely urgent transfers and emergency call attendances View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dennis John William KING · 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
Dennis John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the action plan for addressing ambulance response concerns
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the categorisation process for urgent inter-hospital transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate means for delivering centralised exigent care through regional centres
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances for timely urgent transfers and emergency call attendances
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” Open source report
8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Failure of ambulance investigations to compare attendances and identify learning View source Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma View source Failure to assess, audit and plan for disruption to children’s asthma service access View source Under-resourcing of the asthma and allergy children’s service View source Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma View source Failure of ambulance investigations to identify omitted emergency treatments and access View source Failure to incorporate investigation learning into training and alerts View source Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management View source Failure to involve children directly in asthma service consultations View source Limited availability of trained paediatric endotracheal intubation capability View source Non-mandatory asthma training for health professionals caring for children and young people View source See 8 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
WILLIAM BRIAN KIN GRAY · 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
William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to compare attendances and identify learning
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand :
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, audit and plan for disruption to children’s asthma service access
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances . There was no risk assessment of the impact on the Service , and no audit of whether this was sufficient to manage the Service . There is no contingency plan in place should this issue arise again .
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the asthma and allergy children’s service
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand .
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma
Wider context from the report “(1) Experienced hospital paediatric doctors all gave evidence that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma . The beneficial effects of the administration adrenalin was not considered , William’s presentation on arrival at hospital was falsely reassuring.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to identify omitted emergency treatments and access
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate investigation learning into training and alerts
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated .
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve children directly in asthma service consultations
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of trained paediatric endotracheal intubation capability
Wider context from the report “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedics skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew:
i. The Trust treatment for those aged 12 and over permits endotracheal intubation by those ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on HEMS arriving in sufficient time if the airway cannot be sufficiently managed.
ii. Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation
iii. there is a difference in provision of life-saving treatment in Essex between those over 12 and for children under 12 and HEMS is a charity with very limited resource across a very large county .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory asthma training for health professionals caring for children and young people
Wider context from the report “(5) Training for health professionals who care for children and young people is not mandatory
The National Capabilities Framework for Professionals who care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory
” 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 Authorise specialist-qualified paramedics in the relevant cohort to perform endotracheal intubation, including under-12 patients through specified critical-care roles.
Verbatim wording from the response “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedic skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew:” Source location Response from East of England 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 Advanced Paramedics in Critical Care cars across the region, one per Integrated Care Board area, through the advanced-practice programme.
Verbatim wording from the response “Currently Specialist Paramedic/Advanced Paramedic/Consultant Paramedic roles in Critical Care and HEMS teams are authorised to intubate patients below the age of 12 in the East of England. There are plans to introduce Advanced Paramedics in Critical Care cars across the region, one per Integrated Care Board area, as part of the advanced practice program roll out.” Source location Response from East of England 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 Patient Safety Improvement Response Framework for developing patient-safety systems and learning from incidents.
Verbatim wording from the response “Your report also referred to the Serious Incident investigation and missed opportunities for learning. Since this investigation, the Trust has implemented the Patient Safety Improvement Response Framework, which was produced by NHS England and sets out the approach to developing effective patient safety systems and learning from these incidents. The approval process for identifying actions from patient safety incidents is now more robust in that an Action Setting Group meets fortnightly to review incident reports and set appropriate actions.” Source location Response from East of England 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 Include a case study in the Safety Matters Newsletter covering adrenaline, paediatric airway management and handover communication during critical asthma incidents.
Verbatim wording from the response “In order to raise further awareness, a case study will be included in the Safety Matters Newsletter and the Trust’s pharmacist will include information around the benefits of IM adrenaline being administered to a patient with life-threatening asthma together with the appropriate point to administer this. The aim is to demonstrate to staff the physiological benefits of administering in this situation.” Source location Response from East of England 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 Establish fortnightly Action Setting Group reviews of incident reports to set appropriate actions.
Verbatim wording from the response “Your report also referred to the Serious Incident investigation and missed opportunities for learning. Since this investigation, the Trust has implemented the Patient Safety Improvement Response Framework, which was produced by NHS England and sets out the approach to developing effective patient safety systems and learning from these incidents. The approval process for identifying actions from patient safety incidents is now more robust in that an Action Setting Group meets fortnightly to review incident reports and set appropriate actions.” Source location Response from East of England 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 Broader paramedic intubation is not undertaken because infrequent exposure prevents maintaining competency and creates patient-safety risks.
Verbatim wording from the response “There is strong scientific evidence that endotracheal intubation, like any skill, requires regular exposure and practice to ensure proficiency in those moments when it is needed, and there is evidence of poor success rates without regular exposure and practice. On average, research has shown that the average paramedic may be required to intubate an adult patient between 1-3 times a year. It has also shown that the need to intubate a child is even less than that and is about once every three to four years. These numbers are not sufficient to maintain competency and the skill was removed for patient safety reasons. This is in line with other NHS Ambulance Services across the country. The majority of airways in both adults and children can be managed without intubation but by the use of a Supraglottic airway.” Source location Response from East of England Ambulance Service
Open published response
7 Nov 2023 Michael John VINCENT · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Long lie after a fall in elderly people View source Failure to provide allocated ambulance responses within the expected response time View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael John VINCENT · 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
Michael John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Long lie after a fall in elderly people
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death . Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide allocated ambulance responses within the expected response time
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay , during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin . There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience . Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” Open source report
13 Sep 2023 Geoffrey Douglas HOAD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment View source Continuing delays in ambulance attendance View source Delays in ambulance responses to calls View source Continuing delays in ambulance service attendance to calls View source See 1 more concern
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
Geoffrey Douglas HOAD · 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
Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report “9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital.
10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.
11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers.
12. This concern has been raised at previous inquest.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in ambulance attendance
Wider context from the report “1. Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours.
2. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.
3. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.
4. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.
5. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.
6. Evidence was heard as to the very high call demand overnight on the 6th and 7th August 2022 and with regard to the significant pressure the healthcare system was and remains under.
7. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system.
8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance responses to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue . The Trust is of the view that only by reducing system pressures as a whole, including hospital handover delays and community services being able to deal with their patients, will pressure on the ambulance service be alleviated to enable them to respond effectively and in a timely manner to their patients . This is to a great extent outside the control of the regional EEAST.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in ambulance service attendance to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue .
” 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 Increase patient-facing clinical hours in Norfolk and Waveney.
Verbatim wording from the response “- Additional recruitment with the aim for there to be over 300 more frontline clinicians in place by March 2024. Year on year we have increased patient facing hours by around 9% in Norfolk and Waveney.” Source location Response from East of England 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 Share hospital handover good practice and work with acute hospitals to review processes and suggest quicker patient offloads.
Verbatim wording from the response “EEAST are a member of the Front Door Group looking to improve arrival to handover times. This is chaired by the Deputy Director for Intensive Support from the NHSE/I team. We have shared good practice from West Suffolk and Colchester Hospitals within the group, which is attended by all Acute in the area. EEAST have approached each Acute to review the current process and suggested changes to allow quicker offloads.” Source location Response from East of England 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 Recruit over 300 additional frontline clinicians by March 2024 to increase ambulance capacity.
Verbatim wording from the response “The Trust has a range of specific actions in place to improve response times to patients which include:” Source location Response from East of England 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 Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
Verbatim wording from the response “- The implementation of our Operational Performance and Improvement Plan (OPIP) which is our plan to improve our own efficiency as an organisation and to maximise ambulance availability, I attach a presentation on this with this letter to provide an update on this work.” Source location Response from East of England 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 Run a Norfolk and Waveney improvement week with clinical teams, crews, dispatchers and call handlers to identify causes and solutions for patient delays.
Verbatim wording from the response “EEAST has also been involved in an ‘improvement Week’ which ran between the 9th and 13th October 2023 in Norfolk and Waveney. The clinical teams have been working alongside crews, dispatchers, and call handlers to better understand the issues behind delays for patients and helping identify ways to resolve them.” Source location Response from East of England Ambulance Service NHS Trust
Open published response
22 May 2023 Michael James Francis Bray · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to provide timely ambulance responses to Category 2 calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael James Francis Bray · 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
Michael James Francis Bray was at home on 9 and 10 October 2021 after drinking alcohol and contacting a crisis helpline while considering hanging himself; he died by hanging between about 1:50 am and 5:53 am on 10 October 2021. The report identified concerns about prolonged delays in responding to Category 2 ambulance calls, including persistently above-target response times, alongside issues concerning inter-agency communication, police and ambulance responses, and welfare checks.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely ambulance responses to Category 2 calls
Wider context from the report “Although it could not be safely said when the deceased died, and therefore it could not safely be said that the delay in the ambulance response probably contributed to the death, the concern is that long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.
Bearing in mind the national ambulance target response time for a Category 2 call of an average of 18 minutes, with 90% of calls to be responded to within 40 minutes:
The average Category 2 response time for the East of England Ambulance Service NHS Trust (‘EEAST’) in October 2021, the month of this death, was 56 minutes and 2 seconds.
The same average time for January 2023, the most recent month for which data was available, was 49 minutes and 3 seconds.
Every month since the deceased’s death, EEAST’s Category 2 response time has been above the 90th percentile time of 40 minutes.
The average EEAST Category 2 response time for a given month in the period from October 2021 to January 2023 is over 1 hour, with a standard deviation of about 20 minutes.
Therefore, EEAST’s Category 2 response time remains persistently and consistently far off target.
Although I accept on the evidence that action is being taken, on both local and national levels, to prevent future deaths as a result of this issue, the evidence of the results of such actions to date is that these actions have been demonstrably ineffective and have not resulted in a Category 2 average response time for EEAST that is even close to the target time.
The evidence received was that this issue, and the causes for it and the action required, are not just local in nature, but also national.
” 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 working with NHS England and healthcare partners to improve Category 2 ambulance response times.
Verbatim wording from the response “We are continuing to work with NHSE and our other healthcare partners to improve our response times, particularly in relation to Category 2 calls. Please do not hesitate to contact me should you require any further information.” Source location Response from East of England 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 Category 2 response-time performance is not an issue specific to this Trust, as action is required nationally and locally.
Verbatim wording from the response “You acknowledge that action is being taken on both local and national levels in relation to the C2 response times (as this is not an issue specific to this Trust) however you have stated that the evidence from these actions is that these have been ineffective to date.” Source location Response from East of England Ambulance Service
Open published response
7 Oct 2022 Barbara HOLLIS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Unavailability of emergency ambulances during periods of high service demand View source Failure to follow the correct emergency response pathway 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
Barbara HOLLIS · 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
Barbara Hollis underwent a total left knee replacement and became restless, confused and progressively unwell afterwards. Although an ambulance was requested urgently for transfer to a high dependency unit, the agreed transfer pathway was not followed and attendance was delayed; she died in the early hours of 23 February 2022. The concern was that emergency ambulance availability and response delays could result in future deaths while remedial steps were being assessed.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of emergency ambulances during periods of high service demand
Wider context from the report “4. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service
5. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients . However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the correct emergency response pathway
Wider context from the report “1. EEAST were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect.
” 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 Maintain the Norfolk D1 system call place with stakeholders to discuss lengthy hospital handover delays and interim measures.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” Source location Response from East of England 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 Continue regular executive-level escalation to address worsening hospital handover delays.
Verbatim wording from the response “To highlight the nature of the handover delays, last month we lost 6295 hours of ambulance time outside hospitals in Norfolk waiting to handover, after the 15-minute handover period (i.e., not including that time). This does not account for the hours spent ‘cohorting’ patients, nor the lost manager time supporting this. This can be seen the effect on our C2 response time is hugely significant and correlates directly with delayed handovers. Escalations continue to take place regularly at executive level to try and ease this situation, but the trend nevertheless is still currently worsening.” Source location Response from East of England 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 Review the current delay action plan.
Verbatim wording from the response “The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns. I have attached our current delay action plan that has recently been reviewed.” Source location Response from East of England 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 Category 1 drop-and-go process so crews waiting at hospital can respond to Category 1 calls immediately.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” Source location Response from East of England 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 Category 2 rapid-release programme to enable eligible crews to hand over patients within 10 minutes and respond to Category 2 calls.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” Source location Response from East of England Ambulance Service
Open published response
26 Aug 2022 Christina Avis RUSE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Insufficient emergency ambulance availability for timely patient response 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
Christina Avis RUSE · 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
Christina Avis RUSE underwent a total left hip replacement on 14 December 2021, deteriorated, and died on 15 December 2021 after transfer to hospital was required. The report raises concern about delays in ambulance availability and response during high demand, noting that future deaths may occur while measures to address the issue are assessed.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency ambulance availability for timely patient response
Wider context from the report “1.EEAST were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes.
2. There were no emergency ambulances available to assign to this call due to high call demand.
3. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours , by which time Mrs Ruse had deteriorated further and had been taken back into the FEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours.
It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients . However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.
” Open source report
4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions View source Failure to provide continuous monitoring and risk assessment of detainees subject to restraint View source Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LEON BRIGGS · 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
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
Wider context from the report “1. Adequacy of the local S136 Multi-Agency Policy
Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons:
(i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction)
(ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay ;
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end.
N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCG) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy making.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous monitoring and risk assessment of detainees subject to restraint
Wider context from the report “3. Adequacy of Monitoring of Detainees Subject to Restraint
The expert evidence of Dr ████████ (Consultant Intensivist). Professor ████████ (Consultant Cardiologist) and Dr ████████ (Forensic Pathologist) highlighted the effect that restraint has on detainees – not only in terms of the potential stress to the heart if the detainee struggles against such restraint but also in view of the continuing metabolic disturbance it creates which continues long after any restraint ceases or is removed. Indeed, they all agreed that metabolic disturbance from the restraint was one of the factors in causing Leon’s cardiac arrest and subsequent death. The evidence of Dr ████████ confirmed that the effects of the restraint would, however, have been treatable and that, if appropriate action had been taken, his cardiac arrest would likely have been avoided; indeed, he explained that even if action only had been taken at the point that Leon had become unconscious, the relatively simple steps of placing him in the recovery position in the cell and starting CPR, whilst awaiting emergency help, on the balance of probabilities, would have resulted in his survival.
The Jury through their answers to Questions 33-34 of the Jury Questionnaire not only determined that a failure to monitor Leon appropriately in the cell on 4 November 2013 more than minimally caused or contributed to his death but also concluded, in Box 3 of the Record of the Inquest, that “The inadequate continuous risk assessments and monitoring of Leon resulting in a failure to recognise when Leon became in need of urgent medical attention in the cell ” was one of the most serious failings by emergency services to provide Leon with adequate support.
Since the carrying out of even relatively basic first aid could have made a significant difference to the outcome in this case, it seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases . As the Jury found there were specific failures by the Custody team in this case, consideration could perhaps be given to having additional monitoring in respect of such detainees independent of the Custody team.
The NHS England Patient Safety Alert (2015) gives guidance to NHS staff on post-restraint observations: https://www.england.nhs.uk/wp-content/uploads/2015/12/psa-vital-signs-restrictive-interventions-031115.pdf. Although this has been circulated to some police, it may not be widely known about and even though it may not cover all of the situations which the police will encounter in their work, something similar could be of potential benefit to all police forces across the country.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks
Wider context from the report “2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders
Although, the MHCCG Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia . Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
” 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 Send the updated conveyance guidance to the coroner and share it with regional police forces and mental health partners.
Verbatim wording from the response “EEAST’s Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document ‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review and update has been completed in December 2021. This will also be shared with the regional police forces and mental health partners through the regional Approved Mental Health Practitioner.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
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 approved national section 136 ambulance guidance locally with partner-agency representation.
Verbatim wording from the response “The National Ambulance s.136 Guidance was recently approved (November 2021) by the National Ambulance Service Medical Directors group (NASMED), which is a working group that reports to the Association of Ambulance Chief Executives (AACE). These changes will now be implemented locally and this work is being led by the Bedfordshire AMHPs (on behalf of the Crisis Care Concordat) and the forum includes representation from both EEAST and Bedfordshire Police.” Source location 2021-0330-Response-from-East-of-England-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 Update the community-setting guidance for requesting conveyance of patients detained under the Mental Health Act.
Verbatim wording from the response “EEAST’s Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document ‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review and update has been completed in December 2021. This will also be shared with the regional police forces and mental health partners through the regional Approved Mental Health Practitioner.” Source location 2021-0330-Response-from-East-of-England-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 Deliver Acute Behavioural Disorder and positional-asphyxia training to frontline staff through the annual clinical update.
Verbatim wording from the response “EEAST has also developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia. The commencement of this training session is planned for 2021/2022 for all frontline staff across EEAST as part of the Essential Care Skills, which is EEAST’s annual clinical update.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
Open published response
24 Nov 2020 Sharon Louise Kelly · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property View source Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments View source Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property View source Lack of sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated View source Failure to maintain adequate arrangements for convening an urgent MHS assessment with social services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sharon Louise Kelly · 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
Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property
Wider context from the report “Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated
Wider context from the report “Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp ████████ as to the response on 27 June 2019)
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate arrangements for convening an urgent MHS assessment with social services
Wider context from the report “Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services . (in light of the jury’s findings with regard to the MHA assessment in June 2019)
” Open source report
17 Jun 2019 Oliver Hall · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians View source Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children View source Failure to inform medical professionals of ambulance delays of 39 minutes or less View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Oliver Hall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
Wider context from the report “1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground .
In Oliver’s case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver’s actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician.
In response to their algorithms the NHS 111 Service implemented a disposition of ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service.
However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information .
The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’.
Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children
Wider context from the report “3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee .
This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child .
Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normal range for a six-year-old child. The health professionals involved in Oliver’s case said they had relied on this guidance.
However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response . The health professionals involved in Oliver’s case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above.
Therefore, it is apparent that the significance of Oliver’s heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment , likely to be due to the nature of the conflicting guidance as detailed above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform medical professionals of ambulance delays of 39 minutes or less
Wider context from the report “2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call.
It was identified, that in a septicaemia case similar to Oliver’s (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2.
As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases).
Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less .
Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidly deteriorated.
As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating .
” Open source report
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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 Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.
Verbatim wording from the response “The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system, some of which also use the same triage system (Pathways) as UK 111 providers.” Source location 2019-0198-Response-by-East-of-England-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 Provide sepsis training and embed UK Sepsis Trust guidance in the electronic Clinical Manual for staff.
Verbatim wording from the response “EEAST has, for a number of years followed and endorsed the work of the UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our ‘Clinical Manual’ – an electronic resource available to staff that is designed to augment the guidance offered by JRCALC.” Source location 2019-0198-Response-by-East-of-England-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 Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.
Verbatim wording from the response “Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways.” Source location 2019-0198-Response-by-East-of-England-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 NICE guidance provides clarity on recognising high-risk sepsis, including severe tachycardia thresholds for children aged six to seven years.
Verbatim wording from the response “A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year.” Source location 2019-0198-Response-by-East-of-England-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 Existing endorsement of UK Sepsis Trust and NICE-aligned guidance, training, and the Clinical Manual adequately address paediatric sepsis recognition.
Verbatim wording from the response “EEAST has, for a number of years followed and endorsed the work of the UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our ‘Clinical Manual’ – an electronic resource available to staff that is designed to augment the guidance offered by JRCALC.” Source location 2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
31 May 2019 Christopher Williams · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Incorrect use of triage algorithms by call handlers View source Failure to communicate arranged admission-bed information to ambulance crews View source Delays in ambulance arrival outside Trust guidelines View source Lack of a neurological-deficit triage algorithm View source Failure by call handlers to escalate worsening conditions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Williams · 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
Christopher Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect use of triage algorithms by call handlers
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm .
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm . He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate arranged admission-bed information to ambulance crews
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance arrival outside Trust guidelines
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a neurological-deficit triage algorithm
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious . Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm , the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by call handlers to escalate worsening conditions
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be addressed.
” Open source report
21 Feb 2019 ROBERT CHARLES CHANDLER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 8 Failure of inflatable lifting-chair sections to inflate View source Failure to use safety straps during patient transfer View source Failure to check equipment daily View source Failure to provide pain relief before ambulance transfer View source Inadequate completion of paper incident records View source Failure to conduct a clinical debrief after an incident View source Failure to request assistance when required View source Insufficient charging of electronic incident-recording tablets View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ROBERT CHARLES CHANDLER · 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 Charles Chandler collapsed and suffered a pneumothorax on 24 September 2018. An ambulance arrived 50 minutes after the first telephone call, and he died in hospital on 25 September 2018 from his injury. Concerns included equipment failure and transfer without pain relief or safety straps, incomplete records, inconsistent equipment checks and assistance-seeking, and delayed implementation of investigation recommendations.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of inflatable lifting-chair sections to inflate
Wider context from the report “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use safety straps during patient transfer
Wider context from the report “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check equipment daily
Wider context from the report “(2) Staff are required to ask for assistance when required and are responsible for checking equipment daily . The evidence is that this is not always done .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide pain relief before ambulance transfer
Wider context from the report “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance . He was later diagnosed with a pneumothorax. No safety straps were used.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of paper incident records
Wider context from the report “(3) An electronic tablet was used initially to record the incident but this was not sufficiently charged to record all information. Paper records were not adequately completed.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a clinical debrief after an incident
Wider context from the report “(4) The incident occurred in September 2018 and the internal investigation report with recommendations was completed in January 2019. Recommendations within the Report and in particular a clinical debrief had not taken place at the time of inquest (February 2019)
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request assistance when required
Wider context from the report “(2) Staff are required to ask for assistance when required and are responsible for checking equipment daily. The evidence is that this is not always done .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient charging of electronic incident-recording tablets
Wider context from the report “(3) An electronic tablet was used initially to record the incident but this was not sufficiently charged to record all information . Paper records were not adequately completed.
” 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 Repair the identified faulty Mangar Elk equipment.
Verbatim wording from the response “You will appreciate that equipment can malfunction at times and we do have a process in place in order to manage these issues. Unfortunately on this occasion the individual did not raise an incident at the time, although I can confirm the equipment was identified as faulty and fixed. I will ensure that further investigation takes place in relation to the clinician’s statement that the equipment malfunction was reported as an incident.” Source location 2019-0060-Response-by-East-of-England-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 clinical debrief and use it to reinforce learning about communication with everyone involved.
Verbatim wording from the response “ePCR failure
The Trust encourages all staff to complete electronic Patient Care Records however there are times when this is not possible due to the nature of the incident or if there are technology issues. To ensure this does not impact on patient care, the ambulances are all stocked with paper Patient Care Records and a paper record was completed on this occasion. I can assure you this did not impact on the quality of care provided to the patient at that point in time. Unfortunately, the paper record was not completed to the standards the Trust details within the Patient Records Policy and this has already been addressed with the member of staff and formed part of the clinical debrief, which took place on 6th March 2019.” Source location 2019-0060-Response-by-East-of-England-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 Entonox is not indicated for potential chest injuries; administering pain relief would require IV cannulation instead.
Verbatim wording from the response “In terms of your comments regarding pain relief and safety straps, Entonox is not indicated with potential chest injuries so IV cannulation would be needed to administer the drug. The crew felt to do this they would need to take many layers of clothes off the patient in a cold outside area and it was more appropriate to complete when in the ambulance. The Mangar Elk piece of equipment does not have safety straps attached to it as the safety element is managed by the attending ambulance staff.” Source location 2019-0060-Response-by-East-of-England-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 Testing Mangar Elk function during daily vehicle checks is considered impracticable because inflation and deflation would delay responses.
Verbatim wording from the response “Vehicle/equipment daily checks
The Trust has a process in place for vehicle/equipment daily checks to take place before the start of every shift. The vehicle daily checklist is completed by the crew and identifies any issues with the equipment on the vehicle. There are some exceptions to this if the crew are required to attend to the call immediately, however the general practice is to complete a vehicle daily check prior to the start of shift. It should also be noted that although a check list would identify that this particular piece of equipment is on the vehicle, it would not be practicable to test the function during this check due to the time taken to both inflate and deflate the device prior to responding to any incidents awaiting attendance” Source location 2019-0060-Response-by-East-of-England-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 Paper Patient Care Records are considered sufficient when electronic records cannot be completed and did not affect patient care on this occasion.
Verbatim wording from the response “ePCR failure
The Trust encourages all staff to complete electronic Patient Care Records however there are times when this is not possible due to the nature of the incident or if there are technology issues. To ensure this does not impact on patient care, the ambulances are all stocked with paper Patient Care Records and a paper record was completed on this occasion. I can assure you this did not impact on the quality of care provided to the patient at that point in time. Unfortunately, the paper record was not completed to the standards the Trust details within the Patient Records Policy and this has already been addressed with the member of staff and formed part of the clinical debrief, which took place on 6th March 2019.” Source location 2019-0060-Response-by-East-of-England-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 Annual servicing and the Medical Devices Policy are considered sufficient to manage Mangar Elk faults.
Verbatim wording from the response “Mangar Elk malfunction
The Mangar Elk equipment is used by staff in order to assist patients who have fallen. All devices are serviced on an annual basis in line with the manufacturer guidelines. If a fault is detected then it is managed in line with our Medical Devices Policy and either reported on our incident reporting system or tagged as faulty. It is then assessed by our Clinical Engineering Department and fixed as required.” Source location 2019-0060-Response-by-East-of-England-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 Safety for Mangar Elk use is considered adequately managed by attending ambulance staff, despite the equipment lacking safety straps.
Verbatim wording from the response “In terms of your comments regarding pain relief and safety straps, Entonox is not indicated with potential chest injuries so IV cannulation would be needed to administer the drug. The crew felt to do this they would need to take many layers of clothes off the patient in a cold outside area and it was more appropriate to complete when in the ambulance. The Mangar Elk piece of equipment does not have safety straps attached to it as the safety element is managed by the attending ambulance staff.” Source location 2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
17 Jan 2019 Mark Harris · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Failure to provide the police with the correct identity of the person involved in a welfare call View source Failure to share the informant's contact details and ambulance service CAD information with the police View source Lack of an agreed ambulance–police communication protocol incorporating information helpful to the police View source Failure of the call-handling protocol to state when police attendance is requested to safeguard ambulance personnel View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Harris · 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
Mark Harris was found deceased with a rope around his neck at the home of his ex-partner on 11 January 2016, after expressing suicidal thoughts following his release from police custody. The report identified communication and information-sharing problems between the ambulance service, police control room and attending officers, including the deceased’s name being mis-spelt and uncertainty about the purpose of the police attendance.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the police with the correct identity of the person involved in a welfare call
Wider context from the report “(1) The 999 call was directed to the ambulance service for a welfare check. The suicide protocol was initiated by the call handler to seek information. When the police were called the mis-spelt name of the deceased as HAIS was provided to them together with detail of the nature of the welfare call as “messaging all night threatening to kill himself”. The police attended the address. Had the correct spelling of the name been provided to the police they would have known Mark Harris and his history of suicide attempts . This was a significant problem for an intelligence led service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share the informant's contact details and ambulance service CAD information with the police
Wider context from the report “(3) The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed ambulance–police communication protocol incorporating information helpful to the police
Wider context from the report “(4) There is no agreed protocol between the ambulance and police services facilitating communication to formulate an ambulance service protocol which incorporates information helpful to the police .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the call-handling protocol to state when police attendance is requested to safeguard ambulance personnel
Wider context from the report “(2) It was unclear to the police that they were being asked to attend to safeguard ambulance personnel and not to undertake a welfare check . The protocol used by the call handler did not make provision for that to be stated .
” Open source report
29 Mar 2018 Matthew Luke FAULKNER · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 3 Insufficient EEAS resources for demand View source Delays in handover to hospital View source Unsustainable public demand on the EEAS View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Luke FAULKNER · 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
Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to hospital.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient EEAS resources for demand
Wider context from the report “(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them .
(2) That the current position regarding demand outstripping available resources is not significantly different to that in May 2017 .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in handover to hospital
Wider context from the report “(4) That there are still significant delays on hand-over to hospital , exacerbating the lack of Ambulances being available to answer emergency calls.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsustainable public demand on the EEAS
Wider context from the report “(3) That the demands placed on the EEAS by the public are not sustainable . With, in the region of, only 60% of ambulance attendances resulting in admission to hospital for urgent care.
” 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 Deploy Patient Safety Intervention Teams to emergency departments experiencing prolonged ambulance handover delays.
Verbatim wording from the response “The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter. These teams were deployed to emergency departments across the region where handover delays were continuing past 45 minutes, where no immediate resolution of the situation is apparent and patients are waiting for an ambulance response in the community. The aim was to minimise patient wait and maximise the availability of ambulances. The teams worked collaboratively with emergency department staff to maintain the safety of patients in the department along with ensuring awareness of those 999 patients who are waiting for a response. This scheme stayed in place until March 2018.” Source location 2018-0097-Response-by-East-of-England-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 Collaborate with acute-sector organisations and Clinical Commissioning Groups to resolve hospital handover delays.
Verbatim wording from the response “I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.” Source location 2018-0097-Response-by-East-of-England-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 operational capacity by recruiting frontline staff and providing additional frontline vehicles.
Verbatim wording from the response “In April 2017 NHS England and NHS Improvement commissioned an independent service review to provide recommendations on the Best Service Model, Pricing Review, Capacity and Demand Analysis and the Commissioning Contract/ model. This review was completed by Deloitte as Deloitte and ORH, a company specialising in operational modelling for emergency and health services. The findings were published on 11th May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand. This is now factored into our emergency operations contract which will see a 15% increase over the next two years. This funding will enable the Trust to increase its frontline patient facing staff by 330 full time equivalent by 2020/2021. I enclose a copy of the service review for your information.” Source location 2018-0097-Response-by-East-of-England-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 Ambulance Response Programme standards, including revised call assessment and categorisation.
Verbatim wording from the response “Whilst this independent service review was being undertaken, nationally all ambulance services made significant changes to the way we respond to our patients due to the implementation of the Ambulance Response Programme. The Trust commenced the implementation of these new standards on the 18 October 2017, which involved allowing call handlers more time to assess 999 calls to determine which patients required an immediate response; and changes to the call categorisation. The new system allows for early recognition of life threatening conditions and is designed to free up more vehicles and staff to respond to emergencies. I understand ████████, the Trust’s former Medical Director, wrote to you” Source location 2018-0097-Response-by-East-of-England-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 Continue educating the public about appropriate use of the 999 service.
Verbatim wording from the response “I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.” Source location 2018-0097-Response-by-East-of-England-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 Explore innovative support for patients with complex needs and frequent falls-related calls.
Verbatim wording from the response “I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.” Source location 2018-0097-Response-by-East-of-England-Ambulance-Service
Open published response
17 Nov 2016 Brian Mills · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Failure to manage outstanding emergency calls and waiting times within target response times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Mills · 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
Brian Mills, an 88-year-old man on warfarin, fell at home and sustained multiple injuries, including broken ribs and a bleeding head wound. An ambulance was called, but a rapid response vehicle arrived over two hours later and an ambulance arrived subsequently; he died on 13 April 2016. The principal concern was that consistently high levels of outstanding emergency calls and excessive waiting times could put lives at risk. Evidence heard at the inquest stated that the ambulance delay did not, in this case, cause or contribute to his death.
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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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage outstanding emergency calls and waiting times within target response times
Wider context from the report “(1) Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.
” 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 Increase clinician staffing in Emergency Operations Centres to treat more patients by telephone and refer them to appropriate pathways.
Verbatim wording from the response “These are not response times that we would want or expect but are part of the increasing pressure on our system. A number of mitigating initiatives have been introduced led by the Trust Medical Director to protect patient safety during these periods of pressure when responses to Green patients are delayed. These include increasing the number of clinicians in the Emergency Operations Centres (EOC) to increase the number of patients treated over the phone and referred to appropriate pathways. Following consultation with hospital colleagues we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.” Source location 2016-0416-Response-by-East-of-England-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 Negotiate with regulators and commissioners regarding funding needed to address the Trust’s capacity gap.
Verbatim wording from the response “In line with the Trust's strategic objective to improve service delivery to our patients, we are negotiating with regulators and commissioners on the funding required to meet the acknowledged capacity gap at EEAST. We continue to recruit hundreds of patient facing staff within the financial envelope provided which in the environment of increasing activity is the only sustainable solution to delayed responses to patients.” Source location 2016-0416-Response-by-East-of-England-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 Release ambulance crews from hospital emergency-department queues to attend patients with life-threatening community conditions.
Verbatim wording from the response “These are not response times that we would want or expect but are part of the increasing pressure on our system. A number of mitigating initiatives have been introduced led by the Trust Medical Director to protect patient safety during these periods of pressure when responses to Green patients are delayed. These include increasing the number of clinicians in the Emergency Operations Centres (EOC) to increase the number of patients treated over the phone and referred to appropriate pathways. Following consultation with hospital colleagues we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.” Source location 2016-0416-Response-by-East-of-England-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 Recruit hundreds of patient-facing staff within the available financial envelope.
Verbatim wording from the response “In line with the Trust's strategic objective to improve service delivery to our patients, we are negotiating with regulators and commissioners on the funding required to meet the acknowledged capacity gap at EEAST. We continue to recruit hundreds of patient facing staff within the financial envelope provided which in the environment of increasing activity is the only sustainable solution to delayed responses to patients.” Source location 2016-0416-Response-by-East-of-England-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 The Trust lacks capacity to deliver national NHS response-time targets amid rising demand and an acknowledged capacity gap.
Verbatim wording from the response “In the context of ever growing demand, we also need to be clear that while we are taking every possible step we can, we do not have the capacity available to deliver national NHS Response Times Targets.” Source location 2016-0416-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
2 Nov 2015 Steven David Jackson · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Lack of up-to-date knowledge among general practitioners about epiglottitis in adults View source Lack of effective training of ambulance staff on when to convey a patient to hospital View source Failure to learn from prior events View source Lack of effective training of ambulance staff in use of the sepsis screening tool View source Ineffective use of the sepsis screening tool by ambulance staff View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Steven David Jackson · 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
Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.
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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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
Wider context from the report “1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally . He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective training of ambulance staff on when to convey a patient to hospital
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from prior events
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014 .
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective training of ambulance staff in use of the sepsis screening tool
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively.
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective use of the sepsis screening tool by ambulance staff
Wider context from the report “1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014.
2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively .
3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital.
” Open source report
Concerns raised 1 Insufficient training for identifying whether patients are suitable for community treatment or require hospital transfer 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
Kevin Patrick Hoey · 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
Kevin Patrick Hoey suffered chest pain at home on 14 July 2014 and was initially assessed as suitable to remain at home after ambulance attendance. His condition deteriorated, and he died at home in the early hours of 15 July 2014; the inquest recorded haemothorax and acute aortic dissection as the cause of death. The principal concern was the assessment of whether patients required hospital transfer and the need for training concerning community treatment or hospital transfer.
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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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for identifying whether patients are suitable for community treatment or require hospital transfer
Wider context from the report “East of England Ambulance Service NHS Trust should liaise with East Midlands Ambulance Service NHS Trust in relation to training under the EMAS Paramedic Pathfinder Programme, identifying whether a patient is suitable for treatment in the Community or requires hospital transfer , with a view to East of England Ambulance Service NHS Trust considering introduction of training similar to that under the EMAS Paramedic Pathfinder Programme .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Paramedic Pathfinder Programme to scope implementation within the Trust and assess implications for the current training programme.
Verbatim wording from the response “Following your recommendation, the Paramedic Pathfinder Programme has been discussed at the Trust’s Clinical Quality and Safety Group (CQSG), which is attended by the Locality Directors and a number of senior clinical managers. As Chair of CQSG, I requested that the Paramedic Pathfinder Programme be reviewed by a group of clinicians to scope out how this could be implemented within the Trust and what the implications are to our current training programme. This piece of work is currently ongoing.” Source location 2015-0101-Response-by-East-of-England-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 Consult with EMAS colleagues about the Paramedic Pathfinder Programme.
Verbatim wording from the response “Prior to the inquest, one of the Trust’s Clinical Managers had already met with our EMAS colleagues and discussed the Paramedic Pathfinder Programme, with a view to suggesting that the Trust consider implementing this training. The Trust welcomes any improvements to support paramedics in their decision making and will be reviewing this case to ensure that learning is embedded to mitigate any chance of this being repeated. The Trust would respectfully like to point out that in a case where the initial patient assessment and history taking was completed by another healthcare professional from EMAS, the EEAST clinicians would have taken a professional steer from this first clinical contact.” Source location 2015-0101-Response-by-East-of-England-Ambulance-Service
Open published response
Concerns raised 8 Failure of Emergency Care Assistant and Emergency Medical Technician crews to adhere to the EoE PPCI protocol after PPCI referral View source Lack of training and instruction for Emergency Care Assistants and Emergency Medical Technicians in ECG machine operation and interpretation View source Failure to provide Emergency Care Assistants and Emergency Medical Technicians with attendance at Immediate Life Support courses View source Failure to ensure clinicians with current ALS training attend transfers after activation of the Primary Percutaneous Coronary Intervention protocol View source Failure of ambulance crews to inform community referrers of their life-support training scope View source Lack of specific guidance for contact and continuing dialogue with relatives after next of kin details are established View source Failure to assess Emergency Care Assistants and Emergency Medical Technicians at intervals for compliance with life-support standards and scope of practice View source Failure to ensure ALS-trained clinicians attend Code Red ambulance transfers for patients with acute coronary syndrome View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
STEPHEN ANTHONY BEDFORD · 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
Stephen Anthony Bedford, aged 33, experienced chest pain at a gym on 31 July 2012, collapsed at a health centre, and was diagnosed with an ST elevation myocardial infarction before being transferred to Papworth Hospital, where his death was confirmed. The inquest recorded acute myocardial ischaemia and coronary artery thrombosis, and stated that the outcome might have been different with a more timely transfer to the specialist coronary intervention centre. Concerns included ambulance staff assessment and training, the attendance of appropriately trained paramedics on transfers, adherence to the PPCI protocol, ECG training, and communication with relatives.
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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Care Assistant and Emergency Medical Technician crews to adhere to the EoE PPCI protocol after PPCI referral
Wider context from the report “5. Whether the Trust’s ECA and EMT crews should be made familiar with and instructed to adhere to the EoE PPCI protocol following any PPCI referral from the community or hospital and whether practical guidance in support of the protocol should be given on the lines suggested in the appendix attached.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training and instruction for Emergency Care Assistants and Emergency Medical Technicians in ECG machine operation and interpretation
Wider context from the report “6. Whether ECA’s and EMT’s should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether they should attend the Trust’s ILS Courses.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Emergency Care Assistants and Emergency Medical Technicians with attendance at Immediate Life Support courses
Wider context from the report “6. Whether ECA’s and EMT’s should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether they should attend the Trust’s ILS Courses .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinicians with current ALS training attend transfers after activation of the Primary Percutaneous Coronary Intervention protocol
Wider context from the report “4. Whether the Trusts paramedics, or only those with current ALS training should be mandated to attend all transfers post-activation of the Trusts Primary Percutaneous Coronary Intervention protocol ( Eo PPCI) , as stipulated in that 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance crews to inform community referrers of their life-support training scope
Wider context from the report “(3) Whether at the point of community referral (patient’s home, GP surgery or elsewhere) the referring individual or team are made aware by the ambulance crew of the scope of their training(i.e. BLS, ILS or ALS) to ensure an informed and optimal decision on transfer is taken.
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for contact and continuing dialogue with relatives after next of kin details are established
Wider context from the report “7. Whether contact with and continuing dialogue with relatives should be the subject of specific guidance once next of kin details have been established ,
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess Emergency Care Assistants and Emergency Medical Technicians at intervals for compliance with life-support standards and scope of practice
Wider context from the report “(1) Whether the Trust’s Emergency Care Assistants (ECA) and Emergency Medical Technicians (EMT) are assessed at intervals to ensure compliance with Basic Life Support(BLS) and Immediate Life Support (ILS) standards and scope of practice .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ALS-trained clinicians attend Code Red ambulance transfers for patients with acute coronary syndrome
Wider context from the report “(2) Whether the Trust’s paramedics or otherwise only those with Advanced Life Support (ALS) training should be mandated to attend all Code Red ambulance transfers of patients diagnosed with acute coronary syndrome(ACS)
” Open source report
9 Jan 2014 Albert James HAND · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Delays in conveying patients with head injuries to hospital View source Insufficient ambulance crew capacity to meet emergency needs View source Emergency call protocols putting patients at risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Albert James HAND · 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
Albert James Hand suffered a fall at the Arndale Shopping Centre in Luton on 1 November 2013 and experienced a delay of almost one and a half hours before arriving at hospital, during which his Glasgow Coma Scale fell from 11 to 7. The concerns identified were delays in conveying patients with head injuries, insufficient ambulance crews in the Luton and Bedfordshire area, and emergency-call protocols that may put patients at risk and result in 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in conveying patients with head injuries to hospital
Wider context from the report “(1) That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance crew capacity to meet emergency needs
Wider context from the report “(2) That there are insufficient ambulance crews in the Luton and Bedfordshire area to meet the emergency needs of the community .
” 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 of England Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Emergency call protocols putting patients at risk
Wider context from the report “(3) That the Protocols in place for dealing with emergency calls are putting patients at risk and may result in future deaths.
” 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 clinical coordination in Health and Emergency Operations Centres to provide senior clinical review and adjust call priorities.
Verbatim wording from the response “The organisational priorities outlined above will continue to be augmented with the clinical coordination function within the HEOCs. This function maintains a robust clinical review for those patients that require further interrogation via the telephone in order to gain a more detailed clinical picture of the patient’s condition. This enables the Trust to change the priority assigned to a call based on any significant changes in the patient’s condition. The clinical coordinators will continue to play a key role within the HEOCs to provide senior clinical presence within the rooms.” Source location 2014-0010-Response-by-East-of-England-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 Reduce response cars and increase ambulance availability.
Verbatim wording from the response “To address the issue of response availability in general, the Trust is taking internal action against the six key priorities set. These are:” Source location 2014-0010-Response-by-East-of-England-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 Recruit 400 student paramedics during 2014/15 to increase frontline staffing capacity.
Verbatim wording from the response “The Chief Executive Officer, Dr Anthony Marsh, joined the Trust on 1 January 2014. Dr Marsh has six key priorities for the organisation which include recruiting 400 more staff and providing more ambulances across the whole service. It is recognised that the Trust has had historic staffing problems due to a national shortage of paramedics to recruit to the vacancies, but the Trust has in place a significant recruitment drive which will enable more ambulances to be on the road over the next two years. As such, it is envisaged that patients will receive a timelier and more appropriate response to their 999 calls.” Source location 2014-0010-Response-by-East-of-England-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 Upskill emergency care assistants through staff development into technician, EMT and paramedic roles.
Verbatim wording from the response “To address the issue of response availability in general, the Trust is taking internal action against the six key priorities set. These are:” Source location 2014-0010-Response-by-East-of-England-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 Maximise clinical staffing on frontline vehicles.
Verbatim wording from the response “To address the issue of response availability in general, the Trust is taking internal action against the six key priorities set. These are:” Source location 2014-0010-Response-by-East-of-England-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 Complete and share the Clinical Capacity Review identifying ambulance capacity shortfalls with Clinical Commissioning Groups.
Verbatim wording from the response “The Trust is absolutely committed to ensuring the Trust can consistently respond in a timely manner to all calls. The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.” Source location 2014-0010-Response-by-East-of-England-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 Luton and Bedfordshire generally meet or exceed commissioned emergency-response targets, although vacancies and wider capacity constraints remain.
Verbatim wording from the response “Notwithstanding the priorities set out by Dr Marsh designed to increase resource availability across the whole area covered by the Trust, Luton and Bedfordshire consistently achieve their commissioned target and regularly exceed it across all Clinical Commissioning Groups within the county. The Trust is commissioned regionally to reach 75% of all its life-threatening emergencies within eight minutes. This is in line with the national targets set by the Department of Health. Clearly, due to the events described previously, the Trust was not able to meet this target on this particular occasion.” Source location 2014-0010-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations