Recipient

Emergency Call Prioritisation Advisory Group

First report 27 Jan 2020•Latest report 8 Jul 2025

Recipient record

Reports, concerns and published responses

Other public bodies · Other public body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

8 Jul2025
South London
Concerns raised2
1. Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response
2. Delays in allocation and dispatch of ambulances
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

Miles Robinson · 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

Miles Robinson developed chest pains and vomiting on 19 December 2022 and experienced delays and incorrect triage after his granddaughter called 999. He travelled by Uber to an urgent treatment centre, where he suffered a cardiac arrest, and died at 06:36 after further cardiac arrests. The principal concerns were the incorrect categorisation of the 999 call and the rigidity of the triage system, alongside ambulance allocation and dispatch delays that may place patients reporting a heart attack at risk of death before an ambulance arrives.

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; that does not assign responsibility.
PFD Monitor interpretation
Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response
Wider context from the report
“In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident. MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS. In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes. This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances. ”
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 Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
Delays in allocation and dispatch of ambulances
Wider context from the report
“In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident. MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS. In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes. This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances. ”
Open source report
7 Jun2024
Buckinghamshire
Concerns raised2
1. Lack of ambulance carriage of appropriate antidote medication for on-scene administration
2. Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment
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

Fern Elisabeth Foster · 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

Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.

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; that does not assign responsibility.
PFD Monitor interpretation
Lack of ambulance carriage of appropriate antidote medication for on-scene administration
Wider context from the report
“(2) The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue), whilst trialled elsewhere, is not part of regional or national protocol. Swift access to this in circumstances where ████████ is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases. ”
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 Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment
Wider context from the report
“(1) The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of ████████ (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene, which may provide the only likely means of prevention of death where sufficient quantity has been ingested. ”
Open source report
16 Oct2020
Essex
Concerns raised3
1. Automatic categorisation of abandoned calls as category 3
2. A ceiling of category 3 for categorisation of all reported medical conditions
3. Failure to provide call recordings or full medical information to categorisation decision-makers
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

Sarah Fernyhough · 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

Sarah Fernyhough died at home in the early hours of 22 May 2019 after taking an overdose of venlafaxine, amisulpride and hydroxyzine, as well as cocaine, cannabis and alcohol. The report identified a delay in ambulance attendance and concerns about the categorisation of her call, including the failure to ensure that the relevant call recording or full medical information was reviewed by the person able to upgrade its categorisation.

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; that does not assign responsibility.
PFD Monitor interpretation
Automatic categorisation of abandoned calls as category 3
Wider context from the report
“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
A ceiling of category 3 for categorisation of all reported medical conditions
Wider context from the report
“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide call recordings or full medical information to categorisation decision-makers
Wider context from the report
“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”
Open source report
27 Jan2020
Bedfordshire and Luton
Concerns raised3
1. Failure to code uncertain self-harm ingestion calls as Category 2
2. Failure to code uncertain self-harm ingestion calls as Category 2
3. Failure to maintain timely availability of a double staffed ambulance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Helen Jayne SHEATH · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.

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; that does not assign responsibility.
PFD Monitor interpretation
Failure to code uncertain self-harm ingestion calls as Category 2
Wider context from the report
“(1) Helen’s father first called ambulance services at 18.20 hours on 2018 which was before he had ingested the sodium nitrate. EAS’s investigation report stated that “from the information provided on this call, that Helen had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled “Psychiatric/Abnormal Behaviour/Suicide Attempt” and the call was coded as a Category 3. This call has been audited by the Quality Assurance Team and was correctly coded and the correct set of questions used” …yet a Category 3 call is for patients who have potentially urgent conditions that are not life threatening and yet Helen had a history of suicide ideation and her father was unable to tell, being the other side of the locked door, whether the substance had been taken or not. In view of both Helen’s past medical history and the fact that her father had no knowledge as to whether the substance had been ingested or not at that stage, it seemed to the Court that an assumption that an overdose had been taken ought to have been made and this first call, therefore, coded as a Category 2; ”
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 Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to code uncertain self-harm ingestion calls as Category 2
Wider context from the report
“(3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome. ”
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 Emergency Call Prioritisation Advisory Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain timely availability of a double staffed ambulance
Wider context from the report
“(2) Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call and it was only after a second call was made to ambulance services at 18.48 hours, when the call handler selected the set of questions titled “Overdose/Poisoning/Ingestion” because it was said that it was suggested on this call that she had ingested the substance that the call was coded a Category 2 and that, due to the lack of DSA availability, at 18.57 hours a Rapid Response Vehicle (RRV) was dispatched with the Mental Health Street Triage Team who arrived at 19.05 and 19.11 hours respectively with a different DSA arriving at 19.25 hours. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response

Delays in allocation and dispatch of ambulances

Concerns raised2

Lack of ambulance carriage of appropriate antidote medication for on-scene administration

Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment

Concerns raised3

Automatic categorisation of abandoned calls as category 3

A ceiling of category 3 for categorisation of all reported medical conditions

Failure to provide call recordings or full medical information to categorisation decision-makers

Concerns raised3

Failure to code uncertain self-harm ingestion calls as Category 2

Failure to code uncertain self-harm ingestion calls as Category 2

Failure to maintain timely availability of a double staffed ambulance