Emergency Call Prioritisation Advisory Group (ECPAG)

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First report 24 Oct 2024•Latest report 24 Oct 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Emergency Call Prioritisation Advisory Group (ECPAG) linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Norfolk

    AI-generated summary

    Aran Sean BRADBURY · 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

    On 21 August 2023, Aran Sean Bradbury applied a ligature to his neck, suffered cardiac arrest and was taken to hospital, where he died on 25 August 2023 from hypoxic ischaemic brain injury following hanging. The report raised concern that ambulance triage coding may assign Category 3 rather than Category 2 priority to patients with a history of mental illness who have ingested substances, potentially resulting in a longer wait for an ambulance. In this case, there was a two-hour delay between the 999 call and ambulance dispatch.

    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 Emergency Call Prioritisation Advisory Group (ECPAG); that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code

    Wider context from the report

    “4) I heard oral evidence that: 25-C codes refer to patients with altered levels of consciousness; Code 25-C-1 (which results to a Category 3 prioritisation) refers to patients with an altered level of consciousness and a history of mental illness; Other subsets of Code 25-C exist, including 25-C-2 which refers to patients with an altered level of consciousness who have ingested substances; and that Code 25-C-2 would result to a Category 2 prioritisation. 5) The evidence I heard was that although Mr Bradbury had ingested substances which might have resulted in a 25-C-2 coding (and therefore at Category 2 prioritisation for an ambulance), given that he also had a history of mental illness he was coded as 25-C-1 (and therefore a Category 3 priority) because the system does not allow for consideration of Codes 25-C-2, 25-C-3 etc if it had determined a 25-C-1 code based on the information provided. 6) The operation of this system as described in the evidence I heard could result in patients who might otherwise warrant a category 2 prioritisation being prioritised as Category 3 and therefore wait longer for an ambulance to attend. Patients with a history of mental illness would appear to fall within this group. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026