4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
Responses linked to these concerns
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AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Launch a public consultation on proposed changes to the Standards of Education and Training.
Verbatim wording from the response “We are currently reviewing our Standards of Education and Training (SETs), which set out how education providers must prepare learners for professional practice. These outcome-focused standards ensure education providers are appropriately organised to deliver high-quality education and training. We plan to launch a public consultation on proposed changes this autumn.” Source location Response from Health & Care Professions Council
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 Consider changes to the paramedic Standards of Proficiency during the next scheduled review in 2027–2028.
Verbatim wording from the response “The current versions of our SOPs became effective for our registrants and for new cohorts on education and training programmes from September 2023. We will further” Source location Response from Health & Care Professions Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Standards of Education and Training governing preparation of learners for professional practice.
Verbatim wording from the response “We are currently reviewing our Standards of Education and Training (SETs), which set out how education providers must prepare learners for professional practice. These outcome-focused standards ensure education providers are appropriately organised to deliver high-quality education and training. We plan to launch a public consultation on proposed changes this autumn.” Source location Response from Health & Care Professions Council
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 Setting curricula and designing training courses are outside the respondent’s role.
Verbatim wording from the response “It is not our role to set curricula or design training courses. That is the role of other bodies.” Source location Response from Health & Care Professions Council
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 Other bodies are responsible for setting paramedic curricula and designing training courses.
Verbatim wording from the response “It is not our role to set curricula or design training courses. That is the role of other bodies.” Source location Response from Health & Care Professions Council
Open published response
15 Nov 2023 Lauren Page Smith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 8 Gap in fitness-to-practise oversight for unregistered technicians View source Failure to assess and manage staff fitness to practise after identified deficiencies View source Failure of the ambulance service to implement collective learning from identified ECG training gaps View source Failure to correctly interpret 12 lead ECGs View source Failure to note or act upon auto-diagnostic ECG reports View source Failure to provide accurate information about observations and ECG findings View source Lack of qualitative assessment of ECG training View source Lack of further ECG training after identified incorrect interpretation View source See 5 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
Lauren Page Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.
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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Gap in fitness-to-practise oversight for unregistered technicians
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████ . ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time . I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage staff fitness to practise after identified deficiencies
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles . I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the ambulance service to implement collective learning from identified ECG training gaps
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████ . There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician . Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to note or act upon auto-diagnostic ECG reports
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report .
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about observations and ECG findings
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct , and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Lack of qualitative assessment of ECG training
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training . I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time .
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Lack of further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Add the individual's name to the HCPC Watchlist.
Verbatim wording from the response “However, I have added her name to our Watchlist. This provides that should she attempt to apply for registration in the future, we will take the concerns you have raised with us into account when considering whether to admit her name to the HCPC Register.” Source location Response from Health and Care Profession Council
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 Concerns about an individual not registered with the HCPC fall outside its remit for further investigation.
Verbatim wording from the response “A review of our Register has revealed that ████████ is not registered with us. As the individual is not registered with us, these concerns do not fall within our remit for further investigation.” Source location Response from Health and Care Profession Council
Open published response
29 Nov 2016 Rex Brook Hall · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of paramedic foundation training to cover arm pain as an atypical sign of myocardial infarction View source Lack of formal testing of paramedics’ 12-lead ECG interpretation View source Failure by paramedics to identify obvious ST elevation 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
Rex Brook 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
Rex Brook Hall died at Solihull Hospital on 28 July 2016 after presenting with right arm pain and atrial fibrillation and subsequently suffering a myocardial infarction and cardiac arrest. Paramedic ECGs showed ST elevation, but this was not recognised or reviewed on arrival at hospital. The principal concern was possible deficiencies in paramedic foundation training, including ECG interpretation, recognition of arm pain as an atypical sign of myocardial infarction, and identification of ST elevation.
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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure of paramedic foundation training to cover arm pain as an atypical sign of myocardial infarction
Wider context from the report “That there may be deficiencies in the foundation training of paramedics:
1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG;
2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction ; and
3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012).
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal testing of paramedics’ 12-lead ECG interpretation
Wider context from the report “That there may be deficiencies in the foundation training of paramedics:
1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG ;
2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction; and
3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012).
” 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 Health and Care Professions Council; that does not assign responsibility.
PFD Monitor interpretation Failure by paramedics to identify obvious ST elevation
Wider context from the report “That there may be deficiencies in the foundation training of paramedics:
1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG;
2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction; and
3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012).
” 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 standards of proficiency for possible amendments addressing the concerns raised.
Verbatim wording from the response “The SOPs for paramedics set out the knowledge, skills and abilities individuals must meet and maintain to register with us, and practice safely and effectively as a paramedic. These standards have been revised periodically, to ensure they remain relevant to current practice for the paramedic profession. In relation to the specific points regarding the training of the paramedics in question, the SOPs for paramedics include specific reference to the need for paramedics to:” Source location Response-by-HCPC
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 Liaise with the College of Paramedics about whether the paramedic standards of proficiency should be amended.
Verbatim wording from the response “that all individuals are deemed eligible to apply with us for registration. Once registered, all registrants must continue to maintain their adherence to these standards to remain on the register, including showing evidence of their continuing professional development if audited. We are currently undertaking a review of the SOPs and will liaise with the College of Paramedics on the concerns raised in your report to explore whether any amendments should be made in this regard.” Source location Response-by-HCPC
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations