10 Oct 2025 William John Puplett · Prevention of Future Deaths report North London
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Concerns raised 1 Failure of emergency dispatch questioning to establish availability of tracheostomy suction equipment and a capable person View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
William John Puplett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William John Puplett died on 9 November 2024 after his tracheostomy tube became blocked at home, where there was no working suction unit. He suffered a significant hypoxic injury and died despite treatment; the report states that an earlier ambulance arrival might have prevented his death at that time. The substantive concern was whether emergency dispatch protocols should ask about available suction equipment and the ability to use it, with a Category 1 response if either was absent.
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 International Academies of Emergency Dispatch; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency dispatch questioning to establish availability of tracheostomy suction equipment and a capable person
Wider context from the report “Consideration by the International Academies of Emergency Dispatch to add the following questions when dealing with a patient out of hospital or at home with a tracheostomy tube when there are difficulties with the tracheostomy tube and the patient is experiencing difficulty in breathing.
“Have you got suction equipment available and is there someone with the patient who is able to use the suction equipment ?
And where the answer is no to either or both the result should be a Category 1 response .
” Open source report
22 Mar 2023 Kenneth Michael Adams · Prevention of Future Deaths report Dorset
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Concerns raised 3 Failure of MPDS to account for the duration of persistent bleeding View source Failure of MPDS to recognise significant scalp laceration bleeding as serious haemorrhage View source Failure of MPDS to account for anticoagulant or antiplatelet medication View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Study the potential impact of uniquely coding patients taking anticoagulant or antiplatelet medication who have active bleeding or closed head injuries.
View source
Action
Implement new language defining SERIOUS Haemorrhage and structuring its Key Question to identify persistent, uncontrolled bleeding more definitively.
View source
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AI-generated summary
Kenneth Michael Adams · 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
Kenneth Michael Adams suffered a scalp laceration after an accidental fall on 19 October 2021. He experienced persistent bleeding while taking clopidogrel, but an ambulance did not arrive until 11.56am; he later died in hospital. The principal concerns were that the Medical Priority Despatch System did not adequately account for persistent scalp bleeding, the high blood flow in the scalp, or antiplatelet medication when prioritising the ambulance response.
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 International Academies of Emergency Dispatch; that does not assign responsibility.
PFD Monitor interpretation Failure of MPDS to account for the duration of persistent bleeding
Wider context from the report “1. During the inquest evidence was heard that:
i. A patient, prescribed either antiplatelet or anticoagulant medication, falling and sustaining a scalp laceration that is not “spurting or pouring blood” (the MPDS definition of “uncontrolled bleeding”), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not “spurt or pour” blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as “serious haemorrhage”. Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a “serious haemorrhage”, the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock.
2. I have concerns with regard to the following:
i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient’s predicament and the potential consequences of the continued blood loss.
” 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 International Academies of Emergency Dispatch; that does not assign responsibility.
PFD Monitor interpretation Failure of MPDS to recognise significant scalp laceration bleeding as serious haemorrhage
Wider context from the report “1. During the inquest evidence was heard that:
i. A patient, prescribed either antiplatelet or anticoagulant medication, falling and sustaining a scalp laceration that is not “spurting or pouring blood” (the MPDS definition of “uncontrolled bleeding”), will never reach an MPDS disposition that results in a prioritisation higher than category 3 , regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not “spurt or pour” blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as “serious haemorrhage” . Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a “serious haemorrhage”, the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock.
2. I have concerns with regard to the following:
i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient’s predicament and the potential consequences of the continued blood loss.
” 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 International Academies of Emergency Dispatch; that does not assign responsibility.
PFD Monitor interpretation Failure of MPDS to account for anticoagulant or antiplatelet medication
Wider context from the report “1. During the inquest evidence was heard that:
i. A patient, prescribed either antiplatelet or anticoagulant medication, falling and sustaining a scalp laceration that is not “spurting or pouring blood” (the MPDS definition of “uncontrolled bleeding”), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not “spurt or pour” blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as “serious haemorrhage”. Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a “serious haemorrhage”, the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed . For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock.
2. I have concerns with regard to the following:
i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed . Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient’s predicament and the potential consequences of the continued blood loss.
” 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 Study the potential impact of uniquely coding patients taking anticoagulant or antiplatelet medication who have active bleeding or closed head injuries.
Verbatim wording from the response “4. The IAED is currently studying the potential impact of the unique coding of patients who are taking anticoagulant/antiplatelet medication (blood thinners) who have active bleeding or closed head injuries. Due to the relatively high number of patients receiving this therapy * as compared to the number of patients who are at risk of a poor outcome related to that therapy, there is significant risk of over-triage, which may only make matters worse in areas with limited resources. Another consideration is that those patients who do not meet these criteria will inevitably suffer even longer wait times as a result. *Preliminary data suggests that nearly 22 percent of all patients with a chief complaint of hemorrhage are on blood thinners (30 percent of those aged 60-75 and 41 percent aged 75-90).” Source location Response from International Academics of Emergency Dispatch
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement new language defining SERIOUS Haemorrhage and structuring its Key Question to identify persistent, uncontrolled bleeding more definitively.
Verbatim wording from the response “1. The IAED is currently implementing new language designed to better define the term SERIOUS Haemorrhage and structure the related Key Question in a way that persistent, uncontrolled bleeding is more definitively qualified as SERIOUS Haemorrhage. It is recommended that UK Ambulance Trusts educate EMDs that uncontrolled bleeding should be considered SERIOUS Haemorrhage until proven otherwise.” Source location Response from International Academics of Emergency Dispatch
Open published response
Concerns raised 1 Failure of the emergency dispatch algorithm to account for anticoagulant medication in head injury patients View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roy Middleton · 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
Roy Middleton fell at home on 9 February 2022, sustaining a head injury while taking warfarin. Emergency medical assistance arrived more than six hours after the initial call, and he died in hospital on 10 February 2022 from a traumatic acute subdural haemorrhage. The principal concern was that the emergency dispatch algorithm did not take anticoagulant medication into account when determining the response category for a head injury.
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 International Academies of Emergency Dispatch; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency dispatch algorithm to account for anticoagulant medication in head injury patients
Wider context from the report “The inquest heard that the International Academies of Emergency Dispatch system algorithm does not take into account whether a patient is on blood thinning medication when considering the category of emergency response required . The inquest also heard from a consultant geriatrician that “by the time he arrived at the hospital he was not fit for any intervention”.
I am concerned that if the algorithm isn’t changed to take into account the affect of anti-coagulant medication on a head injury , deaths will occur in the future.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations