Recipient

Lifestar Medical Limited

First report 10 Aug 2025•Latest report 10 Aug 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Lifestar Medical Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Aug2025
Cornwall and Isles of Scilly
Concerns raised7
1. Failure to assess need for hospital conveyance during nurse clinician review
2. Failure to establish ambulance staff role and assessment status
3. Failure to undertake sufficiently broad triage investigation
1. Failure to include available family members in clerking patients with dementia
2. Failure to confirm ambulance staff clinical grade during introductions
3. Failure to ensure reliable sharing of ambulance clinical information between organisations
4. Failure to conduct an independent physical assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Brian Ingram · 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

Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess need for hospital conveyance during nurse clinician review
Wider context from the report
“5) The nurse clinician was asked to review the x-ray only. There did not appear to have been any check as to whether Brian needed to be conveyed to RCHT which may have been appropriate if the complaint of groin pain had been noted. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish ambulance staff role and assessment status
Wider context from the report
“6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake sufficiently broad triage investigation
Wider context from the report
“4) Brian was seen by a triage nurse who ordered a knee x-ray only. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to include available family members in clerking patients with dementia
Wider context from the report
“2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to confirm ambulance staff clinical grade during introductions
Wider context from the report
“1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure reliable sharing of ambulance clinical information between organisations
Wider context from the report
“3) The inquest was told that it will ordinarily be a SWAST ambulance that attends the MIU and there is a process whereby an ACRF can be sent electronically with the relevant past medical history. On this occasion, an LML ambulance attended whose staff work from written Patient Clinical Records. There was a conflict in the evidence as to whether a PCR was provided to MIU staff. One had to be subsequently requested by CPFT to review what had happened on the day. It may be appropriate to review how information is shared between different organisations. ”
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 Lifestar Medical Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct an independent physical assessment
Wider context from the report
“7) The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Failure to assess need for hospital conveyance during nurse clinician review

Failure to establish ambulance staff role and assessment status

Failure to undertake sufficiently broad triage investigation

Failure to include available family members in clerking patients with dementia

Failure to confirm ambulance staff clinical grade during introductions

Failure to ensure reliable sharing of ambulance clinical information between organisations

Failure to conduct an independent physical assessment