19 May 2025 Emily Rose STOKES · Prevention of Future Deaths report North East Kent
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Concerns raised 4 Lack of clarity about responsibility for making pre-alert calls to hospital View source Failure to recognise the seriousness of patients' symptoms View source Insufficient equipment on private ambulances for patient transfer and care View source Insufficient training of ambulance staff to manage patients under the influence of illicit substances View source See 1 more concern
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. 9
Action
Use a pre-event vehicle checklist to standardise and document equipment preparation.
View source
Action
Provide dedicated event medical training and annual refreshers for the event staff team.
View source
Action
Mandate internal clinical escalation through the Clinical Support Line and empower crews to pre-alert hospitals independently when concerned or uncertain.
View source
Action
Develop and benchmark a clinical inventory standard against NHS specifications.
View source
Action
Provide enhanced scenario-based training for event staff covering intoxication, deterioration, escalation, de-escalation and emergencies in dynamic settings.
View source
Action
Create and distribute a Medical Operational Plan for every event, covering staffing, response structure, communications and escalation pathways.
View source
Action
Distribute an event-readiness checklist covering equipment, clinical signs, contacts, escalation, hospital pre-alerts and documentation.
View source
Action
Deliver refresher training for all crews on hospital pre-alert criteria and documentation.
View source
Action
Use the incident and coroner’s findings as a formal case study and embed learning in induction, refresher training, governance, audits and pre-event reviews.
View source See 6 more actions
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AI-generated summary
Emily Rose STOKES · 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
Emily Stokes, a 17-year-old looked after child, became critically unwell after apparently taking MDMA at a music festival and died after suffering a cardiac arrest in hospital. Concerns included limited training of private ambulance staff in managing illicit substance use, unclear responsibility for pre-alerting the hospital, and ambulance equipment that was less comprehensive than that of an NHS ambulance.
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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 Kent Central Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for making pre-alert calls to hospital
Wider context from the report “(2) There was a lack of clarity regarding who had responsibility for making a pre alert call to the hospital and given this young girl was significantly unwell this should have been done. This in part may have been due to the lack of recognition of the seriousness of her symptoms and therefore potentially linked with training of staff.
” 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 Kent Central Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the seriousness of patients' symptoms
Wider context from the report “(2) There was a lack of clarity regarding who had responsibility for making a pre alert call to the hospital and given this young girl was significantly unwell this should have been done. This in part may have been due to the lack of recognition of the seriousness of her symptoms and therefore potentially linked with training of staff.
” 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 Kent Central Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Insufficient equipment on private ambulances for patient transfer and care
Wider context from the report “(3)The ambulance did not have the same equipment which an NHS Ambulance would have on board and was in essence very little more than a means of transport from the venue to the hospital and may have given a false sense of reassurance.
” 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 Kent Central Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of ambulance staff to manage patients under the influence of illicit substances
Wider context from the report “(1) Private ambulance providers were used and the training of the staff involved was minimal , the evidence heard indicated that they had a qualification called First Response Emergency Care level 4 which was a five day course and had little experience or training in relation to management of patients having taken drugs . Given that the teams on site were present and ambulances available at a music event where the risk of drug taking was deemed to be high more training should have been provided to assist the staff in how to safely manage those under the influence of illicit substances .
” 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 Use a pre-event vehicle checklist to standardise and document equipment preparation.
Verbatim wording from the response “Action Taken:” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated event medical training and annual refreshers for the event staff team.
Verbatim wording from the response “1. Creation of a Dedicated Event Staff Team” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate internal clinical escalation through the Clinical Support Line and empower crews to pre-alert hospitals independently when concerned or uncertain.
Verbatim wording from the response “Action Taken:” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and benchmark a clinical inventory standard against NHS specifications.
Verbatim wording from the response “Action Taken:” Source location Response from Kent Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide enhanced scenario-based training for event staff covering intoxication, deterioration, escalation, de-escalation and emergencies in dynamic settings.
Verbatim wording from the response “d. A team of experienced staff is then established to cover public events, depending on the following groupings: especially those involving young persons or known drug-risk environments.” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and distribute a Medical Operational Plan for every event, covering staffing, response structure, communications and escalation pathways.
Verbatim wording from the response “3. Mandatory Medical Operational Plans (MOPs)” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute an event-readiness checklist covering equipment, clinical signs, contacts, escalation, hospital pre-alerts and documentation.
Verbatim wording from the response “6. Deployment of Event Readiness Checklist” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher training for all crews on hospital pre-alert criteria and documentation.
Verbatim wording from the response “• We have clarified our internal clinical escalation protocol, which now mandates that:
◦ If a crew has any concern, they must escalate via the Clinical Support Line, regardless of other clinician directions.
◦ Crews are now explicitly empowered to pre-alert independently if in doubt.” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the incident and coroner’s findings as a formal case study and embed learning in induction, refresher training, governance, audits and pre-event reviews.
Verbatim wording from the response “Learning from the Incident” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staff deployed were trained and certified for their roles, although event environments required additional specific and scenario-based training.
Verbatim wording from the response “We confirm that the staff deployed on the day were trained and certified according to their roles. However, on reflection, we recognise that deployment of our staff to events where there was an increased likelihood of young persons in attendance coupled with the potential for illicit substance use, required a higher level of specific and scenario-based training.” Source location Response from Kent Central Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The vehicle had equipment considered appropriate for the authorised scope of care, despite not necessarily matching NHS ambulance specifications.
Verbatim wording from the response “The vehicle used was a High Dependency Vehicle (HDV) and was staffed by a crew of two staff members. The vehicle was equipped with monitoring equipment, oxygen, resuscitation tools, and all other kit deemed appropriate for the level of care authorised under their scope.” Source location Response from Kent Central Ambulance Service
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations