5 Jun 2026 Prabhabi Cangi · Prevention of Future Deaths report North London
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Concerns raised 4 Lack of guidance for clear and readable photographs of ECGs uploaded to attendance records View source Lack of a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital View source Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital View source Failure to advise patients with abnormal ECGs to show the ECG copy to their GP View source See 1 more concern
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Prabhabi Cangi · 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
Prabhabi Cangi died in Harefield Hospital on 12 August 2025 after an ST elevation myocardial infarction, following an ambulance attendance at her home where she had chest pain, breathlessness and an abnormal ECG. The principal concerns were the lack of a clear pathway for specialist interpretation of abnormal ECGs when paramedics did not convey patients to hospital, and the failure to ensure that intermittent chest pain, breathlessness and abnormal ECG findings resulted in hospital assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for clear and readable photographs of ECGs uploaded to attendance records
Wider context from the report “That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital
Wider context from the report “That there is no clear pathway for interpretation of ECG traces to a specialist doctor , when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital
Wider context from the report “That Intermittent symptoms of:-
- Chest Pain
- Breathlessness
- Abnormal ECG with some ST elevation (using one or more leads)
did not result in the patient being taken to the nearest emergency hospital .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise patients with abnormal ECGs to show the ECG copy to their GP
Wider context from the report “That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital).
” 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 Commence a trial transmitting ECGs to Heart Attack Centre clinicians for early interpretation and specialist referral.
Verbatim wording from the response “In addition, clinicians have access to real-time clinical support. This includes the LAS Clinical Hub, which is staffed by experienced Clinical Support Managers, and an on-call clinical advice line involving senior paramedics and doctors where escalation is required. In the latter part of this year, the LAS is due to commence a trial of ECG transmission to HAC clinicians for assistance with interpretation. This will facilitate early cardiology review and admission to specialist units as required.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ECG transmission pilot results and use the findings to inform future pan-London ECG transmission approaches.
Verbatim wording from the response “Notwithstanding this, LAS will reinforce guidance relating to intermittent symptoms and potential ACS scenarios; re-emphasise best practice regarding provision of ECG copies and patient advice; and strengthen messaging regarding the clarity and quality of ECG image capture pending implementation of enhanced digital solutions. Furthermore, an interim review of results from ECG transmission to cardiologists is planned once the pilot phase of this programme of work is complete. This will be used to guide and inform future approaches to ECG transmission pan London.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence procurement of ECG monitoring equipment requiring direct ECG data upload into electronic patient care records.
Verbatim wording from the response “The Trust is also due to commence a procurement process for new ECG monitoring equipment during the 2026–2027 financial year. A key requirement of this procurement is the capability for ECG data to be uploaded directly from monitoring equipment into the ePCR, thereby removing the need for photographic capture and improving accuracy and quality of records.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-emphasise best practice for providing ECG copies and advising patients to share them with subsequent healthcare professionals.
Verbatim wording from the response “Where a patient is not conveyed to hospital it is standard practice to provide the patient with a paper copy of the ECG; and the patient is advised to retain the ECG and present it to any healthcare professional with whom they subsequently have contact, such as their General Practitioner. In addition to this, following clinical interaction with patients, completed clinical” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce guidance and training on intermittent symptoms and presentations suggestive of acute coronary syndrome.
Verbatim wording from the response “Conversely, where ECG abnormalities are new, unexplained, or accompanied by symptoms suggestive of acute coronary syndrome, conveyance or onward referral is clearly indicated. LAS clinicians are therefore required to apply clinical judgement in interpreting ECG findings within the wider clinical context, rather than relying solely on automated ECG interpretation or isolated abnormalities.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver further ECG-focused training and updated myocardial infarction guidance through the 2026–2027 Core Skills Refresher cycle.
Verbatim wording from the response “LAS provides ongoing training and reinforcement of ECG interpretation through:” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen staff messaging on capturing clear, readable ECG images pending enhanced digital recording solutions.
Verbatim wording from the response “LAS policy requires that all clinical images, including ECG photographs, are relevant, clear, and clinically usable. The Trust recognises the importance of ensuring that ECG images recorded within the ePCR are consistently clear and readable and will reinforce this requirement with staff.” Source location Response from London Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical guidance, support lines and planned ECG transmission provide sufficient mechanisms for paramedic escalation and specialist review.
Verbatim wording from the response “This guidance is available to all LAS clinicians and is accessible in real time via Trust-issued electronic devices.” Source location Response from London Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing paramedic training, national guidance and holistic clinical assessment are considered sufficient for recognising and managing suspected acute coronary syndrome.
Verbatim wording from the response “Paramedics are required to complete an approved Bachelor of Science degree prior to registration with the Health and Care Professions Council (HCPC). Training in ECG acquisition and interpretation is a core component of paramedic education and includes recognition of features consistent with myocardial ischaemia and infarction, including STEMI.” Source location Response from London Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing practice provides patients with ECG copies and advice to share them with subsequent healthcare professionals, including general practitioners.
Verbatim wording from the response “Where a patient is conveyed to hospital a photograph or digital copy of the ECG is uploaded to the electronic Patient Care Record (ePCR); and a paper copy of the ECG is routinely provided to the receiving clinician during handover.” Source location Response from London Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policy requires ECG images to be clear, relevant and clinically usable, providing an established control for record quality.
Verbatim wording from the response “Quality and Clarity of ECG Records” Source location Response from London Ambulance Service
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24 Apr 2026 Edward Muwanga · Prevention of Future Deaths report Inner West London
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Concerns raised 5 Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation View source Lack of awareness of the section 135 MHA 1980 process View source Fragmented healthcare record systems limiting the visibility and communication of important patient safety information View source Failure to locate and identify information about a section 135 MHA 1980 warrant View source Failure to make a detailed and measured assessment of a person’s situation View source See 2 more concerns
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AI-generated summary
Edward Muwanga · 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
Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.
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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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the section 135 MHA 1980 process
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980 , and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to locate and identify information about a section 135 MHA 1980 warrant
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant , together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a detailed and measured assessment of a person’s situation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 Enable visibility of Computer Aided Dispatch information within electronic patient care records to support clinical decision-making.
Verbatim wording from the response “From the 12th of May, functionality to improve visibility between internal systems has been enabled (notably, the visibility of information currently only visible within the Computer Aided Dispatch [CAD] system in ePCR), which will assist clinicians to access extra incident information, and support decision-making. This will provide the additional benefit of improved visibility of information which has been received by other providers into our CAD (e.g. from the Metropolitan Police Service (MPS) or NHS 111 services).” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider interoperability enhancements between the London Care Record and National Record Locator through OneLondon procurement and strategic planning.
Verbatim wording from the response “• LAS is actively involved and participates in the One London board, as the only pan-London NHS provider organisation. Other representation is at an ICB and regional level. Consideration will be given to developing further enhancements to improve interoperability between the LCR and the NRL—notably the consumption of NRL records in the LCR in the first instance, with a longer-term view to also share information from the LCR into the NRL. This will be achieved through influence over the direction of procurement and strategic planning of the OneLondon 2.0 programme and approach to London Care Record, UCP and enhanced access and integration.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote Universal Care Plans to partner organisations for shared care planning.
Verbatim wording from the response “Promotion of Universal Care Plans
The Trust has and continues to highlight the clear benefits to our partners in the development of UCP for shared care plans across organisations.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue LAS participation in the NHS England Single Patient Record Programme Clinical Reference Group.
Verbatim wording from the response “• LAS’s paramedic Chief Clinical Information Officer and Deputy are part of the NHS England Single Patient Record Programme Clinical Reference Group. The SPR programme aims to create one unified, secure view of a patient’s health and care information across NHS services in England. This intends to bring together data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will focus on two identified priority areas (maternity and frailty) before looking to further areas. It is intended that the first priorities will go live around 2028.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborating with regional, local and national partners to improve shared-care planning and cross-organisation information access.
Verbatim wording from the response “It also provided an overall understanding that better integration, the ability to surface key critical information quickly and the developments by future digital improvements are essential to the prevention of future harm. The Trust will continue to work closely with partner organisations to ensure patient safety remains central to future developments.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain implemented clinical-system flags and visual prompts alerting clinicians to shared care plans and key documents.
Verbatim wording from the response “Digital Flagging and Visual Prompts
Enhancements have been implemented (Appendix 2) within clinical systems to alert clinicians when a shared care plan or key document exists, prompting review at the point of care. This is intended to reduce the likelihood that critical information is overlooked due to time pressures in clinical interactions or where patient data records contain a volume of information.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with the Universal Care Plan team to develop mental-health and catheter-care personalised care-planning use cases.
Verbatim wording from the response “• At an operational level, LAS has a touchpoint every other month with the Universal Care Plan team and are part of the UCP Clinical Transformation & Advisory Group. The LAS will be collaborating with the UCP team to develop the next two specific personalised care planning use cases – mental health and catheter care. As part of this learning, consideration for how information may be consistently shared across the correct platforms will be made. In addition, the UCP have received confirmation of funding which will allow them to develop integrations into two key Electronic Patient Records (Rio and Mosaics) to support the sharing of mental health information in the UCP.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed updated shared-record access and safety-information guidance in induction, mandatory training and clinical communications.
Verbatim wording from the response “Training and Clinical Guidance
Training materials and clinical guidance have been reviewed and updated to reinforce expectations regarding:” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed mental health assessment guidance in the electronic patient care record tool to prompt care-record review.
Verbatim wording from the response “LAS Mental Health Team - Actions Taken - Planned and Ongoing Work
Recent updates undertaken have strengthened the emphasis on accessing care records and obtaining collateral information in Mental Health assessments. The ePCR Mental Health Documentation Tool (launched in November 2025) now includes embedded Mental Health assessment guidance prompting crews to review care records, with further enhancements to be proposed through planned and ongoing work.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver expanded mental-health training through induction, conferences, rolling case-based sessions, targeted sessions and accessible resources.
Verbatim wording from the response “Alongside this, training within LAS has been expanded significantly to include:” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate electronic patient care records with the London Care Record to reduce access time and streamline navigation.
Verbatim wording from the response “Improved System Integration
The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop further visibility, access and flagging for National Care Record Service documents and alerts within clinical systems.
Verbatim wording from the response “Improved System Integration
The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS.” Source location 2026-0235 - Response from NHS Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional London Care Record flagging is not considered beneficial because most attended patients already have information published there.
Verbatim wording from the response “- In-context access is supported in Adastra, and was enabled for ePCR in November 2025.
- As most patients we attend will contain information published to the London Care Record, flagging is not deemed to bring any benefit.” Source location 2026-0235 - Response from NHS Ambulance Service
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8 Jul 2025 Miles Robinson · Prevention of Future Deaths report South London
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Concerns raised 2 Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response View source Delays in allocation and dispatch of ambulances View source
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.
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AI-generated summary
Miles Robinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Miles Robinson developed chest pains and vomiting on 19 December 2022 and experienced delays and incorrect triage after his granddaughter called 999. He travelled by Uber to an urgent treatment centre, where he suffered a cardiac arrest, and died at 06:36 after further cardiac arrests. The principal concerns were the incorrect categorisation of the 999 call and the rigidity of the triage system, alongside ambulance allocation and dispatch delays that may place patients reporting a heart attack at risk of death before an ambulance arrives.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response
Wider context from the report “In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident.
MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS.
In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack . The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack ; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response , with an average response time of 7 minutes and 90% of calls responded to within 15 minutes.
This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation and dispatch of ambulances
Wider context from the report “In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident.
MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS.
In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes.
This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances .
” Open source report
10 Nov 2023 Frances Ann NEWBURY · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Failure to administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Frances Ann NEWBURY · 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
Frances Ann Newbury was found unconscious and not breathing at home on 20 May 2023 after reportedly taking drugs the previous evening; the inquest recorded acute poly drug toxicity, substance misuse disorder and chronic lung disease as the medical causes of death. The principal concern was that paramedics did not administer Naloxone despite being informed of illicit drug use and observing signs associated with drug use, which may affect outcomes in other cases.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated
Wider context from the report “Despite paramedics being informed that Ms Newbury had taken illicit drugs the previous evening (albeit the report being of ████████) and obvious signs of ‘popping’ scars on her legs from ████████, Naloxone was not administered.
Although in Ms Newbury’s case, it would have made no difference, I am concerned that in another case it may.
This is not the first inquest in which I have queried why Naloxone has not been administered to patients (with a opiate misuse history) when all other potential reversible causes have been treated.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request a review of current JRCALC guidance on naloxone use in opioid-related cardiac arrest.
Verbatim wording from the response “Overall the evidence base suggests that where cardiac arrest is established and confirmed from opioid use, naloxone has limited efficacy in reversing the cardiac arrest. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidance advise the use of naloxone in cardiac arrest, noting that this has been unchanged and more recently the empirical reviews of the clinical evidence have been undertaken. I have asked that our Consultant Paramedics and Associate Clinical Directors who both are members of the JRCALC resuscitation group, request that a review is undertaken of JRCALC current guidance in light of the emerging clinical evidence, in respect of opioids.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with agencies regularly contacting opioid users to improve naloxone availability.
Verbatim wording from the response “increasing the accessibility to public access defibrillators and trained responders and we are working with our agencies who have regular contact with opioid users around utility of naloxone to be available to them.” Source location Response from London Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide high-concentration naloxone on specialist Trust resources for cases involving potentially potent synthetic opioids.
Verbatim wording from the response “That said, the LAS is absolutely of the view that naloxone should be administered where a patient presents with respiratory depression and/or is peri (near) arrest, in this instance it is recognised to be lifesaving and we absolutely support its administration. In March 2022, the London Ambulance Service initiated the availability of high concentration naloxone on specialist resources utilised by the Trust. This was in recognition of the potential for highly potent synthetic opioids where stronger doses of naloxone may be required. We are also highly supportive of naloxone in community programs, for those where there is a high risk of overdose.” Source location Response from London 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 For confirmed cardiac arrest, standard resuscitation with high-quality compressions and ventilation should take priority over naloxone.
Verbatim wording from the response “Asphyxia (deprivation of oxygen), through the respiratory depression (reduction in an individual’s breathing), develops and this leads to further cerebral hypoxia. Ultimately it is the hypoxia/hypercarbia which cause a diminishing cardiac output and may finally sadly result in a patient’s cardiac arrest. Where a patient is in cardiac arrest, there is immediate and ongoing artificial ventilation in an attempt to correct any ventilatory failure. Naloxone is a competitive antagonist (receptor site blocker) for the opioid and its administration aims to diminish the effects of the opioid, however, once a patient is in cardiac arrest (as opposed to respiratory arrest) the focus should be on high quality standard life support including artificial ventilation, chest compressions and adrenaline administration.” Source location Response from London 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 Established cardiac arrest and absent immediate opioid-use evidence meant naloxone was not mandated and would not have changed the outcome.
Verbatim wording from the response “Whilst it is recognised that Ms Newbury had a long term history of opioid use, naloxone was not considered at the time of the cardiac arrest as there was no immediate history of opioid use and a clinically feasible cause of the arrest was identified, which was a current infection. The resuscitation attempt focused on high quality chest compressions and effective ventilation. It was recognised by the clinicians that naloxone would not have reversed the effects of ████████. The information reported to the clinicians at the time of attendance was that Ms Newbury had taken ████████ the previous evening.” Source location Response from London Ambulance Service
Open published response
27 Apr 2022 Raphael Jeffery Gill · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Failure to use emergency transport for a medical emergency View source Failure to prevent arrest-related bias from influencing assessment of urgency View source Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport View source Failure to recognise the combination of seizures and cocaine as a medical emergency View source See 1 more concern
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
Raphael Jeffery Gill · 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
Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use emergency transport for a medical emergency
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens , and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent arrest-related bias from influencing assessment of urgency
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide . It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the combination of seizures and cocaine as a medical emergency
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency , a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” 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 Share the PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.
Verbatim wording from the response “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.” Source location Response from London 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 Review existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.
Verbatim wording from the response “The LAS recognises that the paramedic drove the ambulance to the hospital while her clinically more junior, non-registered colleague remained in the back of the ambulance attending to Mr Gill. On balance, despite Mr Gill being fully conscious, there was a history of abnormal muscle rigidity and possible seizure activity. As such, we would be of the view that the paramedic should have attended to Mr Gill in the rear of the ambulance as they would have been immediately available in the case of deterioration. As you would be aware from the documentation provided to you at the close of the inquest, the LAS has a number of guidance notices and policies around the primacy of care. In addition, there is helpful documentation from the professional regulator on this subject.” Source location Response from London 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 Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.
Verbatim wording from the response “In terms of the LAS, we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.” Source location Response from London 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 Existing JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.
Verbatim wording from the response “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.” Source location Response from London Ambulance Service
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 The care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.
Verbatim wording from the response “Mr Gill was appropriately assessed and promptly conveyed to the local emergency department. We have considered carefully if a pre-alert call (blue lights and sirens) was required. On balance, there is no absolute indication that a pre-alert call was required. Mr Gill was fully conscious and able to walk himself into the hospital. The time from the arrival of the conveying ambulance on the scene to leaving the scene for the hospital was 18 minutes; this is rapid and, on balance, could not have been quicker. Therefore, the LAS believes that this does not reflect a lack of urgency, that the time spent on the scene was not excessive and it does not follow that the fact Mr Gill was under arrest influenced the timeliness or appropriateness of his assessment, management or of his care.” Source location Response from London Ambulance Service
Open published response
28 Sep 2021 Richard Boateng · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable View source Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency View source Failure to update and clarify ambulance-service guidance for crews and control staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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. 5
Action
Update policies OP14 and OP23 to incorporate case learning and step-by-step processes for frontline and control-room handling of vulnerable missing-person calls.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021. View source
Action
Issue staff bulletins requiring frontline and control-room staff to search, verify, escalate vulnerable missing-person cases to police, and document actions.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2021. View source
Action
Communicate the finalized policy updates through staff bulletins, intranet, email, digital applications, and related staff communication channels.
Stated plannedThe respondent said that this action was planned when they made their response on 14 October 2021. View source
Action
Convert OP14 into a unified, hyperlinked live online document accessible to staff on scene through tablets.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021. View source
Action
Provide the updated policies to new starters and embed them in training for new entrants to relevant teams.
Stated plannedThe respondent said that this action was planned when they made their response on 14 October 2021. View source See 2 more actions
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AI-generated summary
Richard Boateng · 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
Richard Boateng became very unwell after contacting his GP surgery and was later found on a street bench. Police and ambulance services attended, but he died from Covid 19 shortly after arriving at hospital; concerns included the handling of urgent GP calls, communication between ambulance and police services, and practical guidance for police when ambulances were unavailable.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable
Wider context from the report “(3) College of Policing. Due to the Covid pandemic, no ambulances were available when police attended to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in an emergency if no ambulances were available. However, the policy included no practical guidance as to how that could be achieved mitigating the risks . I heard that the Metropolitan Police Service is updating the guidance. However, I am concerned that other forces across the country may also lack such practical guidance , which is of particular concern due to ongoing pandemic and the demands that may continue of ambulance services.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency
Wider context from the report “(1) NHS England. A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinik which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments , and there is no guidance available to surgeries as to how to mitigate the risks of this .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update and clarify ambulance-service guidance for crews and control staff
Wider context from the report “(2) London Ambulance Service. The GP called LAS concerned about Richard’s welfare. LAS attended his home address. Richard was not there. The LAS paramedic advised his sister to call the police. The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact. I was told that national guidance on this issue was published in the summer. To date, neither guidance to crews nor to control had been updated to make the LAS guidance clearer to those applying it .
” 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 Update policies OP14 and OP23 to incorporate case learning and step-by-step processes for frontline and control-room handling of vulnerable missing-person calls.
Verbatim wording from the response “We gave evidence at the inquest that national guidance for dealing with missing/absconded patients was issued to ambulance Trusts in April 2021. Although our policies OP14 and OP23 are already compliant with that guidance, it was accepted in evidence that it would be beneficial to update them to include a specific step by step process to be actioned by control room in conjunction with frontline staff.” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
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 Issue staff bulletins requiring frontline and control-room staff to search, verify, escalate vulnerable missing-person cases to police, and document actions.
Verbatim wording from the response “Pending finalisation of the updates to those policies we have developed bulletins for the above cohorts of staff, which have been issued.” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
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 Communicate the finalized policy updates through staff bulletins, intranet, email, digital applications, and related staff communication channels.
Verbatim wording from the response “When the new policies are released, this will be communicated in the same ways” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
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 Convert OP14 into a unified, hyperlinked live online document accessible to staff on scene through tablets.
Verbatim wording from the response “Work was already underway to make OP14 a unified document that would be a single ‘point of truth’ for information when staff have a specific policy or clinical question, with hyperlinks to relevant information and documents. This means that it will be a ‘live’ document online which can be updated quickly. It can be accessed by staff via their tablets when on scene.” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
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 the updated policies to new starters and embed them in training for new entrants to relevant teams.
Verbatim wording from the response “as the staff bulletins, as set out above. New starters will also be provided with them and the policies will be embedded in training for new entrants to the relevant teams at LAS.” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
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 Existing policies were already compliant with national guidance, although a more specific step-by-step process was considered beneficial.
Verbatim wording from the response “We gave evidence at the inquest that national guidance for dealing with missing/absconded patients was issued to ambulance Trusts in April 2021. Although our policies OP14 and OP23 are already compliant with that guidance, it was accepted in evidence that it would be beneficial to update them to include a specific step by step process to be actioned by control room in conjunction with frontline staff.” Source location 2021-0335-Response-from-London-Ambulance-Service_Published
Open published response
8 Jul 2021 Nadeem Ahmed · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to convey accurate and relevant clinical information from scene paramedics to the HEMS desk View source Failure of HEMS desk paramedics to request full clinical parameters View source
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
Nadeem Ahmed · 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
Nadeem Ahmed lacerated his brachial artery after putting his hand through a glass pane at his home on 8 February 2020. He suffered hypovolaemic shock, later cardiac arrest and multiple organ ischaemia, and died at the Royal London Hospital on 13 February 2020. The principal concerns were incorrect triage of emergency calls and failures to communicate accurate and relevant clinical information to the HEMS team, which denied him the opportunity to receive life-saving treatment before cardiac arrest.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey accurate and relevant clinical information from scene paramedics to the HEMS desk
Wider context from the report “At the time of communication between the LAS paramedic on scene and the paramedic on the HEMS dispatch desk, Mr Ahmed was in a state of hypovolemic shock. He had a very high pulse rate, a very high respiratory rate, had suffered a brief loss of consciousness and had a concerning pallor. This clinical picture was not conveyed to the HEMS desk. The paramedic on scene did not offer accurate and relevant clinical information. The paramedic on the HEMS desk requested only the GCS and not the full clinical parameters.
There may be an opportunity to improve communication between the HEMS dispatcher and paramedics on scene, by joint training and/or provision of a check-list for key clinical parameters to be shared. A senior HEMS clinician gave evidence at the inquest. He stated that video link communication might also aid in the transfer of relevant and accurate clinical information.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of HEMS desk paramedics to request full clinical parameters
Wider context from the report “At the time of communication between the LAS paramedic on scene and the paramedic on the HEMS dispatch desk, Mr Ahmed was in a state of hypovolemic shock. He had a very high pulse rate, a very high respiratory rate, had suffered a brief loss of consciousness and had a concerning pallor. This clinical picture was not conveyed to the HEMS desk. The paramedic on scene did not offer accurate and relevant clinical information. The paramedic on the HEMS desk requested only the GCS and not the full clinical parameters.
There may be an opportunity to improve communication between the HEMS dispatcher and paramedics on scene, by joint training and/or provision of a check-list for key clinical parameters to be shared. A senior HEMS clinician gave evidence at the inquest. He stated that video link communication might also aid in the transfer of relevant and accurate clinical information.
” Open source report
18 Feb 2021 Mr Kevin Clarke · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to balance detainee and wider risks before restraint decisions View source Inadequate supervision and collective leadership during challenging incidents View source Failure to define and apply criteria for releasing restraints View source Failure to provide effective continuous Safety Officer monitoring of detainee health and safety View source Inadequate health-professional input into police officer training View source Failure of paramedic leadership and risk assessment in detention situations View source Inadequate police training in detainee health and safety monitoring View source Failure of police and paramedics to obtain and exchange clinical advice on conveyance decisions View source Failure to provide adequate briefings for supervisory risk assessment View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Kevin Clarke · 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
Mr Kevin Clarke, a 35-year-old man with complex mental health problems, was found by police in a disturbed state on 9 March 2018, restrained, and later suffered a fatal cardiac arrest in an ambulance. The report identified concerns about inappropriate restraint, inadequate monitoring and dynamic risk assessment, unsuitable conveyance and positioning, insufficient clinical assessment, and weaknesses in training, leadership and supervision by police and ambulance staff.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to balance detainee and wider risks before restraint decisions
Wider context from the report “3. The protocols of the MPS require a Safety Officer to monitor the detainee’s health and safety in restraint situations. Evidence heard suggested that this was either not carried out or was ineffective. No officer challenged the decision to cuff the detainee when he started to get up and the Safety Officer at the time agrees he did not consider whether his illness made the decision unreasonable , as laid out in ACPO guidance. An officer agreed that the risks of restraint to the detainee were not balanced against the risks to everyone from not restraining . The Safety Officer at the head changed several times, making any monitoring of trend difficult and for a critical period the most inexperienced officer was the Safety Officer, who was unaware of the benefits of looking at gums or nails. At the time he was escorted, the Safety officer agreed that the face could not be observed as it was hidden by a hood. The risks are further augmented by the MPS submission that it is not always possible to identify a safety officer in all incidents.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision and collective leadership during challenging incidents
Wider context from the report “4. There was serious inadequacy of supervision . The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion . An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint. She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint, unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision.
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define and apply criteria for releasing restraints
Wider context from the report “4. There was serious inadequacy of supervision. The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion. An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint. She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint , unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision .
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective continuous Safety Officer monitoring of detainee health and safety
Wider context from the report “3. The protocols of the MPS require a Safety Officer to monitor the detainee’s health and safety in restraint situations. Evidence heard suggested that this was either not carried out or was ineffective . No officer challenged the decision to cuff the detainee when he started to get up and the Safety Officer at the time agrees he did not consider whether his illness made the decision unreasonable, as laid out in ACPO guidance. An officer agreed that the risks of restraint to the detainee were not balanced against the risks to everyone from not restraining. The Safety Officer at the head changed several times, making any monitoring of trend difficult and for a critical period the most inexperienced officer was the Safety Officer, who was unaware of the benefits of looking at gums or nails . At the time he was escorted, the Safety officer agreed that the face could not be observed as it was hidden by a hood . The risks are further augmented by the MPS submission that it is not always possible to identify a safety officer in all incidents .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate health-professional input into police officer training
Wider context from the report “1. Evidence was adduced that the police officer training programmes are run by a specialist in officer safety, the core being Officer Safety Training, and another module being Emergency Life Support (ELS) and a bolt on of ABD Training. The focus of ELS is upon action in the event of a cardiac arrest, so that there is little attention to given to health and safety of the detainee in non-emergency situations and an inadequate input by health professionals . It is illustrated by the officer who said that he had not been taught how to measure vital signs as part of monitoring a detainee. The expert consultant physician who viewed the video of restraint observed a highly abnormal fast breathing rate, but none of the officers had noticed this at the time.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of paramedic leadership and risk assessment in detention situations
Wider context from the report “2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic , who appeared to have insufficient seniority or experience to know what to do in a detention situation . Equally there was a lack of expectation or request by police for her input and advice. My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision, says she left it to them to decide, although preferring a safer method and then later changes her evidence.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate police training in detainee health and safety monitoring
Wider context from the report “1. Evidence was adduced that the police officer training programmes are run by a specialist in officer safety, the core being Officer Safety Training, and another module being Emergency Life Support (ELS) and a bolt on of ABD Training. The focus of ELS is upon action in the event of a cardiac arrest, so that there is little attention to given to health and safety of the detainee in non-emergency situations and an inadequate input by health professionals. It is illustrated by the officer who said that he had not been taught how to measure vital signs as part of monitoring a detainee . The expert consultant physician who viewed the video of restraint observed a highly abnormal fast breathing rate, but none of the officers had noticed this at the time .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police and paramedics to obtain and exchange clinical advice on conveyance decisions
Wider context from the report “2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic, who appeared to have insufficient seniority or experience to know what to do in a detention situation. Equally there was a lack of expectation or request by police for her input and advice . My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision , says she left it to them to decide , although preferring a safer method and then later changes her evidence.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate briefings for supervisory risk assessment
Wider context from the report “4. There was serious inadequacy of supervision. The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion. An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint . She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint, unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision.
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” 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 Include Acute Behavioural Disturbance assessment, management and interagency communication in the next mandatory refresher training.
Verbatim wording from the response “As we set out in evidence, we are committed to regularly increasing the knowledge and awareness of our front line staff on ABD and it will be included in our next CSR training which is due to be delivered in 2021/2022, subject to Covid-19 restrictions.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
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 Monitor and review Category 1 triage for suspected Acute Behavioural Disturbance, coordinate its use with police, and share upgrade information with emergency operations staff.
Verbatim wording from the response “We provided evidence at the inquest to detail our commitment to continue to monitor and review the use of ‘Category 1’ triage for potential ABD patients, which goes above the national position and demonstrates the importance the LAS place on ensuring the timeliest of response to this cohort of patients. The LAS will continue to work with the police to ensure this is used correctly to maximise benefit and will continue to highlight the need for accurate and concise sharing of information where ABD is suspected. The LAS will continue to ensure that the process for this upgrade of calls is shared within our Emergency Operations Centres.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
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 Acute Behavioural Disturbance education to Clinical Team Managers through two online learning sessions.
Verbatim wording from the response “In order to optimise this response, ABD training will be to be included in the package of education for our Clinical Team Managers (CTM) to further develop their core knowledge. There are two, two hour online learning sessions taking place before the end of April 2021. Staff attendance will be recorded and each CTM will have to report to confirm that they have completed the sessions.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
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 Share updated clinical guidelines digitally with clinicians through personally issued tablet devices.
Verbatim wording from the response “The LAS has established processes for sharing updated clinical guidelines digitally with our clinicians through the use of personally issued tablet devices to staff which alert staff to updated clinical guidelines. Further to this my Chief Medical Officer, who chairs the National Medical Directors Group is keen to ensure the regular update of these guidelines to reflect learning. ████████ our Clinical Practice Development Manager for Critical Care, who you heard from at the inquest, has joined the group which is developing and reviewing these guidelines and the learning from Mr Clarke’s death has been presented to the chair of the JRCALC guidelines group.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
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 a process to proactively dispatch a Clinical Team Manager or Incident Response Manager to suspected Acute Behavioural Disturbance calls involving police.
Verbatim wording from the response “In order to further enhance the clinical leadership and experience on scene we are working through a process of change in order to pro-actively send either a Clinical Team Manager (or an Incident Response Manager) to calls where the Metropolitan Police Service or other Police service, report a case of suspected ABD. This must not distract from the timely response of the nearest available clinical resource, but will provide additional leadership on scene to support our frontline clinicians and enhance patient care.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
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 Acute Behavioural Disturbance training to all clinicians joining the service.
Verbatim wording from the response “We provided evidence at the inquest to explain how our front line staff are trained and kept up to date via our Core Skills Refresher (CSR) training, which is a mandatory annual programme providing front line staff with three, eight hour training sessions per year. Since 2010 our crews have been trained in ABD and in recognition of how important ABD training is for ambulance clinicians, we have introduced ABD training as part of the syllabus for all clinicians joining the LAS and this will be incorporated for every new entrant who joins from April 2021.” Source location 2021-0046-Response-from-London-Ambulance-Service-Redacted
Open published response
29 May 2020 Master Omarian Brooks · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Dispute over hospital destination during ambulance transfer View source Failure to inform the GP of patient deterioration 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
Master Omarian Brooks · 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
Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Dispute over hospital destination during ambulance transfer
Wider context from the report “2. There was also a distressing dispute between the ambulance crew and parents as to which hospital Omarian should be taken , in the event he was not taken to the nearest hospital at the insistence of his parents (although in this instance the delay was not found to have contributed to the death).
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of patient deterioration
Wider context from the report “1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after , he would have been admitted to hospital with a real prospect of the infection being successfully treated.
” 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 Update the policy governing conveyance of patients to appropriate hospital destinations by the end of October 2020.
Verbatim wording from the response “The LAS’s position on conveying patients to the most appropriate destination is detailed in OP/014 Managing the Conveyance of Patients Policy and Procedure. During the inquest you were advised by Ms ████████, Sector Senior Clinical Lead, that this policy was due to be updated but due to the current pandemic it has not been possible for the LAS to carry out this update. The LAS endeavours to update this policy by the end of October 2020.” Source location 2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
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 Conveyance to the nearest emergency department was indicated, and the crew acted correctly under policy.
Verbatim wording from the response “Given that this patient was presenting with a potentially critical illness, conveyance to the nearest emergency department was indicated. The acceptable exceptions to conveying the child to another hospital would not apply in an emergency situation for the nearest unit not being equipped to deal with a paediatric patient. This would not have been the case with Lewisham Hospital which has a paediatric emergency department.” Source location 2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Open published response
12 Mar 2020 Mitica Marin · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to review the defibrillator during resuscitation View source LP15 defibrillator defaulting to manual mode View source Failure to activate the LP15 defibrillator in automatic mode 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
Mitica Marin · 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
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review the defibrillator during resuscitation
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation LP15 defibrillator defaulting to manual mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to activate the LP15 defibrillator in automatic mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 Deliver human-factors training covering communication, active listening, speaking up and decision-making bandwidth to tutors and relevant clinical staff.
Verbatim wording from the response “A further six staff are due to undertake the ‘Train the Trainer’ program. We also have a full day of training in areas specific to human factors (communication, active listening, speaking up as part of a team, and how bandwidth impacts decisions and communications) which we hope to be in a position to roll out in July/August” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Review delayed-defibrillation cases and complete thematic analysis to identify contributory factors and mitigation actions.
Verbatim wording from the response “It was also recognised that the delay in defibrillation of Mr Marin was not an isolated incident for the Trust. In order to address incidents of delayed defibrillation, the LAS undertook a review of similar cases and completed a thematic analysis report in December 2019. The updated Action Plan from this report is attached for your reference.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Continue reviewing defibrillator procurement options through clinical-equipment tender processes and encourage manufacturers to develop automatic AED-mode functionality.
Verbatim wording from the response “Efforts are being made to investigate devices which have in-built technology to potentially bypass the need for a clinician to have to remember to put the device in AED mode (for example, a device that would automatically switch the device to AED mode when defibrillator pads were applied). At this point in time, we have not located a specific device on the market with this functionality which is also sufficiently robust for the ambulance market.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Issue clinical guidance mandating initial AED-mode use on LP15 defibrillators during cardiac arrests.
Verbatim wording from the response “Paramedic A cited the training actions the LAS had undertaken around the fundamental importance of prompt defibrillation, where clinically indicated. In addition to this, the LAS has produced clinical update material to mandate that on all cardiac arrests the LP15 defibrillator should initially be placed in AED mode.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Train clinical education and standard tutors in human factors so they can deliver the content through the core-skills refresher programme.
Verbatim wording from the response “Further to the evidence you heard in respect of training, in addition the LAS is continuing to progress ‘human factors training’ to focus on optimising staff performance through better understanding of behavioural interactions with each other and the environment. This is especially pertinent for operational staff who deal with chaotic, emotional scenes and where no two scenes are the same.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Place AED-mode reminder stickers on LP15 defibrillators and communicate the change through station management, bulletins and the intranet.
Verbatim wording from the response “From August 2019 large yellow indicators (stickers) with ‘push analyse for AED mode’ were placed on LP15 defibrillators to act as an alert reminder to users to switch the machine into AED mode. This was communicated to staff via station management as well an update in our Routine Information Bulletin (RIB) which is emailed to all staff and also available on the intranet. We have also sought to ensure that devices used in training reflect this change.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Incorporate AED-mode use and cardiac-arrest priority training into mandatory quarterly core-skills refresher training.
Verbatim wording from the response “This has also been incorporated this into the core skills refresher (CSR) training which all clinical staff undergo in the LAS.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Setting LP15 defibrillators to AED mode by default was considered impractical because of operational use and potential unintended consequences.
Verbatim wording from the response “Our Clinical Practice Development Manager gave evidence setting out that it was technically possible for the LP15 defibrillator to be set to AED mode as default, which would require the user to actively have to switch it off when managing a patient who did not require defibrillation. He went on to explain that this option has been considered by the Trust’s medical directorate but the evidence gathered in consideration of the best option to mitigate against clinicians being distracted and/or overwhelmed managing multiple tasks at a busy scene, indicates that to set the LP15 defibrillator to AED mode as default was not overtly practical for a day to day use.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 No sufficiently robust defibrillator with automatic AED-mode functionality has been found for ambulance use.
Verbatim wording from the response “Your report also requests that I address the matter of procurement decisions regarding the future supply of defibrillators.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
Open published response
27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 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
Shanté Andrée Marie TURAY-THOMAS · 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
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical advice .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored in.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective improvement .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored in.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” 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 Continue participating in ambulance user groups to share data, discuss cases, exchange learning, and support triage-system improvements through feedback mechanisms.
Verbatim wording from the response “The LAS, as an MPDS user for its 999 services and an NHS Pathways user for its 111 services, attend the relevant user groups with other ambulance trusts and fully participate in such meetings, where there is the opportunity to share data back and forth, discuss cases of note and share learning in order to make continual improvements through the feedback mechanisms to NHS Digital and the Academy at PDC process. The LAS will discuss the findings of PFD report at such user groups. Ultimately, however, changes to how the triage system operates are a matter for the International Academies of Emergency Dispatch (IAED) where MPDS (owned by PDC) is concerned, or for NHS Digital under their national clinical governance group where NHS Pathways is concerned.” Source location 2020-0124-Response-from-London-Ambulance-Service_Redacted.pdf
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 ECPAG, acting for NHS England, controls ambulance categorisation and can identify inconsistencies between NHS Pathways and MPDS.
Verbatim wording from the response “The Response Priority for each MPDS determinant descriptor – being the Category of ambulance it requires – is set by ECPAG. This is because final decisions about categorisation are made by ECPAG on behalf of NHS England. It is, therefore, this organisation (if any) who has the power to take the action the learned Coroner is seeking at sub-paragraph 3 above and, where possible, would be capable of identifying any inconsistencies between the categories of ambulance assigned to dispositions within the NHS Digital system on the one hand and PDC on the other, in relation to acute anaphylaxis and otherwise.” Source location 2020-0124-Response-from-London-Ambulance-Service_Redacted.pdf
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 Changes to MPDS and NHS Pathways operation are matters for IAED and NHS Digital respectively.
Verbatim wording from the response “The LAS, as an MPDS user for its 999 services and an NHS Pathways user for its 111 services, attend the relevant user groups with other ambulance trusts and fully participate in such meetings, where there is the opportunity to share data back and forth, discuss cases of note and share learning in order to make continual improvements through the feedback mechanisms to NHS Digital and the Academy at PDC process. The LAS will discuss the findings of PFD report at such user groups. Ultimately, however, changes to how the triage system operates are a matter for the International Academies of Emergency Dispatch (IAED) where MPDS (owned by PDC) is concerned, or for NHS Digital under their national clinical governance group where NHS Pathways is concerned.” Source location 2020-0124-Response-from-London-Ambulance-Service_Redacted.pdf
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 ECPAG has limited ability to align NHS Pathways and MPDS because the systems use different methodologies.
Verbatim wording from the response “From the LAS’s understanding however, there are limitations to ECPAG’s ability to align the two systems – NHS Pathways and MPDS – as they operate differently and have two different methodologies for reaching a triage decision.” Source location 2020-0124-Response-from-London-Ambulance-Service_Redacted.pdf
Open published response
1 Nov 2019 Xavier Thomas and 10 others · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 7 Counter-terrorism investigation concerns View source Emergency response concerns for terrorist attacks View source Concerns about rental vehicles used in terrorist attacks View source Communications concerns View source Protective security concerns View source Concerns about locating casualties View source Medical equipment and training concerns View source See 4 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
Xavier Thomas and 10 others · 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
On 3 June 2017, three attackers carried out vehicle and knife attacks at London Bridge and Borough Market, killing eight victims: Xavier Thomas, Christine Archibald, Sara Zelenak, James McMullan, Sébastien Bélanger, Alexandre Pigeard, Kirsty Boden and Ignacio Echeverría Miralles de Imperial. The report identifies substantive concerns relating to protective security, counter-terrorism investigations, emergency response, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Counter-terrorism investigation concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations , emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Emergency response concerns for terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks , communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Concerns about rental vehicles used in terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Communications concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications , locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Protective security concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security , counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Concerns about locating casualties
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties , medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Medical equipment and training concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training , and rental vehicles used in terrorist attacks.
” 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 Deliver updated JOP training to specialist responders and commanders through classroom learning, tabletop exercises and multi-agency live exercises.
Verbatim wording from the response “Upon implementation of the updated JOPs in February 2019, the LAS commenced a 10 week specialist training programme for specialist responders and commanders (Hazardous Area Response Team (HART), Tactical Response Unit (TRU) and commanders) to ensure they are all fully up to date with the changes and new” Source location 2019-0332-Response-by-London-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 Conduct a seven-day live trial placing LAS and London Fire Brigade staff in the Metropolitan Police control room to test situational information sharing.
Verbatim wording from the response “A further live trial is planned for seven days in February 2020. This will see a member of LAS staff based in the MPS control room with a member of the LFB, 24 hours a day. The focus on this test of concept is on timely and accurate situational information sharing. The outcome of this trial will be analysed and a recommendation based upon the results will be considered for approval by the Autumn of 2020.” Source location 2019-0332-Response-by-London-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 Implement the updated Joint Operating Principles for marauding terrorist attacks, including flexible zoning and deployment arrangements.
Verbatim wording from the response “As previously reported to you, the Joint Operating Principles of the Emergency Services (JOPs) were completely reviewed and updated in February 2019 and have now been implemented as a new first edition. This new edition JOPs is titled “Responding to a Marauding Terrorist Attack (MTA)”, rather than “Marauding Terrorist Firearm Attack (MTFA)” as was the case in the 2017 edition. The new edition covers various types of attack methodology,” Source location 2019-0332-Response-by-London-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 Continue multi-agency MTA training exercises involving specialist and non-specialist responders, including exercises testing casualty location and information flow.
Verbatim wording from the response “Alongside classroom based learning, the LAS also continues to instigate and engage in multi-agency MTA training exercises with both specialist and non-specialist responders, including the ‘Yellow Penguin’ Exercise which took place at Chessington on 6th March 2019, Exercise ‘Red Botham’ at Lords cricket ground on 30th March 2019 and Exercise ‘Eleanor’ on 28th October 2019. In addition, the LAS has undertaken further live exercises to test particular elements of the JOPs. An example of this is the ‘Autumn Falls’ Exercise which specifically included the identification and response to hidden casualties. This took place on 29th September 2019 and was a large scale Chemical Biological Radioactive and Nuclear (CBRN) training exercise.” Source location 2019-0332-Response-by-London-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 Analyse the control-room co-location trial and submit a recommendation for approval based on its results.
Verbatim wording from the response “A further live trial is planned for seven days in February 2020. This will see a member of LAS staff based in the MPS control room with a member of the LFB, 24 hours a day. The focus on this test of concept is on timely and accurate situational information sharing. The outcome of this trial will be analysed and a recommendation based upon the results will be considered for approval by the Autumn of 2020.” Source location 2019-0332-Response-by-London-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 Review available technical solutions for identifying casualty and emergency responder locations, including solutions used by other emergency services.
Verbatim wording from the response “NARU is nationally responsible for the development and introduction/improvement of technical measures to assist in the identification of casualties and emergency service responders during an MTA. Its aim is to ensure that a nationally-appropriate solution is adopted, which can be accessible by all emergency services (fire, police and ambulance). In light of its experience in responding to these incidents, the LAS has been asked by NARU to take the lead in the practical assessment of these technical measures. Over the course of 2020, the LAS will therefore be working to review the technical solutions currently available, including those which are already in use by different emergency services.” Source location 2019-0332-Response-by-London-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 LAS teaching on MTA response and casualty collection points to Metropolitan Police tactical firearms commanders.
Verbatim wording from the response “In addition to multi-agency training exercises, the LAS is providing a teaching session to MPS staff on their tactical firearms commander course, which explains the LAS response to MTA incidents and the principles of casualty management from an LAS perspective. The session covers the LAS duty of care to patients, the incident response structure and the LAS’ pre-determined response to a MTA or major incident. It also includes information relating to casualty collection points, the purpose and benefit of these and how the MPS and LAS work jointly during a major incident. It stresses the importance of recognising and understanding the use and process of casualty collection points and how patients can be brought directly to them for medical treatment.” Source location 2019-0332-Response-by-London-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 Ensure 24/7 control-room staffing capability for the designated casualty-location roles and train staff using updated action cards.
Verbatim wording from the response “Control room staff will be updated in the use of this process so that, by March 2020, there will always be a staff member on shift on a 24/7 basis with the capability of undertaking these roles. Training for control room staff will be provided via a bulletin for Emergency Operations Centre (EOC) staff with the updated Action Cards. It is also currently being explored whether a session can be incorporated into the EOC Core Skills Refresher training for the coming year.” Source location 2019-0332-Response-by-London-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 Update Specialist Operations Centre action cards to incorporate learning from the Autumn Falls exercise.
Verbatim wording from the response “Exercise ‘Autumn Falls’ was located at a sporting stadium; information relating casualty locations within the stadium was fed into the LAS Specialist Operations Centre (SOC) and venue control room to test the information flow between these areas and the exercise commanders and responders on the ground, to ensure that information was received and acted on, finding the exercise casualties hidden within the stadium. The exercise debrief is currently being finalised, and by the end of January 2020 the relevant SOC action cards will be updated to ensure that learning is incorporated in LAS response to incidents. Further information can be found below regarding the location and assistance of casualties.” Source location 2019-0332-Response-by-London-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 Designate control-room roles to identify, record, cross-reference and communicate casualty locations during MTA and major incidents.
Verbatim wording from the response “In response to the issues raised by the 2017 incidents and the learning from the “Autumn Falls” Exercise, when faced with a MTA or major incident, the LAS has decided to designate specific roles SOC Manager (to ensure the information is considered and actioned), a Critical Loggist and a SOC Allocator) within its control room to undertake the task of identification and recording of casualty locations to prevent any oversight. Those within these roles are tasked with ensuring that identification of casualty locations is prioritised, with a designated person responsible for constantly monitoring, reviewing and linking up information coming from members of the public via 999 calls, the MPS CAD link, ES5 (emergency services radio communication channel) and the call log so that it can be actioned.” Source location 2019-0332-Response-by-London-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 updated JOP training to frontline non-specialist staff through the CSR 2019 programme.
Verbatim wording from the response “provisions within the JOPs. This training, which is the consolidation of the theoretical learning form the JOPs and its practical application in a multi-agency scenario setting includes classroom based learning, table top exercises and physical MTA live exercises conducted on a multi-agency basis (alongside the Metropolitan Police Service (MPS) and London Fire Brigade (LFB)). Currently, 100% of TRU staff, 94% of HART staff and 100% of commanders have completed the training. In addition to specialist teams and commanders, the LAS is also training front line (non-specialist) staff through its annual Core Skills Refresher (CSR) training programme, identified as CSR 2019. This particular module started on 1st December 2019 and will run through to 31st March 2020.” Source location 2019-0332-Response-by-London-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 Further review LAS training packages, action cards and procedures in light of the Regulation 28 report and NARU’s formal review.
Verbatim wording from the response “In order to embed the changes in the February 2019 JOPs, the LAS training and exercise packages, action cards and procedures were reviewed. March 2019. These will be undergoing a further review following the detail of your Regulation 28 Report and following the formal review by NARU. This further review will be complete by September 2020.” Source location 2019-0332-Response-by-London-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 Interoperability with existing or new computer-aided dispatch systems means technical solutions are not anticipated to be implemented before 2023.
Verbatim wording from the response “As the successful roll out of these technical solutions will be dependent on their interoperability with current or any new Computer Aided Dispatch (CAD) systems, it is not anticipated that a solution will be implemented before 2023.” Source location 2019-0332-Response-by-London-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 NARU is nationally responsible for developing and introducing technical measures to identify casualties and emergency responders during marauding terrorist attacks.
Verbatim wording from the response “NARU is nationally responsible for the development and introduction/improvement of technical measures to assist in the identification of casualties and emergency service responders during an MTA. Its aim is to ensure that a nationally-appropriate solution is adopted, which can be accessible by all emergency services (fire, police and ambulance). In light of its experience in responding to these incidents, the LAS has been asked by NARU to take the lead in the practical assessment of these technical measures. Over the course of 2020, the LAS will therefore be working to review the technical solutions currently available, including those which are already in use by different emergency services.” Source location 2019-0332-Response-by-London-Ambulance-Service
Open published response
31 Jul 2019 Fern-Marie CHOYA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to include pregnancy information in pre-hospital alerts View source Failure to involve the obstetric team in the assessment and management of pregnant emergencies View source Failure to communicate pregnancy information effectively on hospital arrival View source Delays in recognising pregnancy and calling the obstetric team View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fern-Marie CHOYA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Fern-Marie Choya died from hypovolaemic shock caused by massive intra-abdominal bleeding following rupture of the abdominal gravid uterus during a monochorionic diamniotic pregnancy. Concerns included failure to communicate her pregnancy during the pre-hospital alert and on hospital arrival, a 16-minute delay in recognising the pregnancy and calling the obstetric team, and treatment focused on possible pulmonary embolism before free fluid was identified.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include pregnancy information in pre-hospital alerts
Wider context from the report “1. The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice.
However, they failed to include in that alert the information that Ms Choya was pregnant . This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the obstetric team in the assessment and management of pregnant emergencies
Wider context from the report “3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pregnancy information effectively on hospital arrival
Wider context from the report “2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively .
It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it.
In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising pregnancy and calling the obstetric team
Wider context from the report “2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively.
It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it.
In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called .
” 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 Update pre-alert guidance to require the EOC to ask for other specific and critical information during information read-back.
Verbatim wording from the response “To support crews and the EOC, the LAS has also recently re-issued guidance (on 12 August 2019) to clarify the relevant details expected during pre-alert calls, to ensure that the appropriate clinical team is present on a patient’s arrival. This guidance stipulates the CASMEET mnemonic (please see attached Bulletin). As a result of our learning from Ms Choya’s death, the LAS has extended this guidance to include a request from the EOC for ‘any other specific and critical information’ at the end of the radio transmission when they repeat the information provided back to the crew. Operational staff will be made aware of this change.” Source location 2019-0281-Resposne-by-London-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 Update joint maternity training to include EOC staff alongside operational, midwifery and maternity support staff.
Verbatim wording from the response “We have also already recognised a gap in understanding of maternity calls, between the EOC, frontline operations and maternity units. As such, the LAS has undertaken extensive learning around handovers and this will continue as part of the joint learning with the Whittington Hospital. The LAS uses Managing Maternity Emergencies in Pre-Hospital Setting’ which was established in 2015. The LAS Practice Leads for pre-hospital maternity care updated this joint training in April 2019 to include staff working within the EOC. This was initially in response to identified areas for improvement regarding the communication and management of maternity calls from midwives working in the pre-hospital setting. Every multi-professional maternity training now involves operation road staff, EOC staff and midwives as well as maternity support workers.” Source location 2019-0281-Resposne-by-London-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 Complete an EOC observation session for the crew to support learning from the incident.
Verbatim wording from the response “Prior to the Inquest, a meeting was held with the crew regarding this incident and feedback provided during this de-brief meeting. In addition, the crew are also to attend an observation session in the EOC for learning purposes (to be completed by 14 October 2019). Furthermore, the relevant Clinical Team Leader will be reviewing, with the crew, what they have learnt from that session and seeking confirmation that they will be following a structured approach every time they share information with the EOC about patients or hand them over to an emergency department in the future.” Source location 2019-0281-Resposne-by-London-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 Assess the feasibility of adding a handover audit mechanism to the developing electronic patient care record specification.
Verbatim wording from the response “As part of this handover procedure, receiving teams are expected to observe a 30 second “hands off eyes on time” period to ensure quiet whilst vital information is conveyed using the ATMIST AMBO (age, time, mechanism/medical complaint, injuries/information related to complaint, signs, treatment – allergies, medication, background/history, other information) mnemonics. The LAS will be rolling out the extension of this handover tool/procedure to all receiving centres, as per the attached handover documents. Work will also be done to ascertain the feasibility of establishing a handover audit mechanism in the specification of the Electronic Patient Care Record (EPCR) that is being developed by the LAS alongside the introduction of its replacement Computer Aided Dispatch (CAD) system.” Source location 2019-0281-Resposne-by-London-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 Roll out the cardiac-arrest handover procedure and ATMIST AMBO tool to all receiving centres.
Verbatim wording from the response “As part of this handover procedure, receiving teams are expected to observe a 30 second “hands off eyes on time” period to ensure quiet whilst vital information is conveyed using the ATMIST AMBO (age, time, mechanism/medical complaint, injuries/information related to complaint, signs, treatment – allergies, medication, background/history, other information) mnemonics. The LAS will be rolling out the extension of this handover tool/procedure to all receiving centres, as per the attached handover documents. Work will also be done to ascertain the feasibility of establishing a handover audit mechanism in the specification of the Electronic Patient Care Record (EPCR) that is being developed by the LAS alongside the introduction of its replacement Computer Aided Dispatch (CAD) system.” Source location 2019-0281-Resposne-by-London-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 Develop a comprehensive cardiac-arrest handover procedure with tertiary centres to ensure key clinical information reaches receiving teams.
Verbatim wording from the response “The LAS has liaised with tertiary centres to develop a comprehensive handover procedure in relation to cardiac arrests, ensuring that relevant and key important clinical information is shared with the receiving team.” Source location 2019-0281-Resposne-by-London-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 Make operational staff aware of the updated pre-alert guidance.
Verbatim wording from the response “To support crews and the EOC, the LAS has also recently re-issued guidance (on 12 August 2019) to clarify the relevant details expected during pre-alert calls, to ensure that the appropriate clinical team is present on a patient’s arrival. This guidance stipulates the CASMEET mnemonic (please see attached Bulletin). As a result of our learning from Ms Choya’s death, the LAS has extended this guidance to include a request from the EOC for ‘any other specific and critical information’ at the end of the radio transmission when they repeat the information provided back to the crew. Operational staff will be made aware of this change.” Source location 2019-0281-Resposne-by-London-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 Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.
Verbatim wording from the response “Prior to the Inquest, a meeting was held with the crew regarding this incident and feedback provided during this de-brief meeting. In addition, the crew are also to attend an observation session in the EOC for learning purposes (to be completed by 14 October 2019). Furthermore, the relevant Clinical Team Leader will be reviewing, with the crew, what they have learnt from that session and seeking confirmation that they will be following a structured approach every time they share information with the EOC about patients or hand them over to an emergency department in the future.” Source location 2019-0281-Resposne-by-London-Ambulance-Service
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 The failure to communicate pregnancy information involved both the crew and emergency operations centre, not the emergency operations centre alone.
Verbatim wording from the response “Notwithstanding the fact that our further review of the transcript has indicated that it was both the crew and the EOC, rather than the EOC alone which failed to pass on the information that Ms Choya was pregnant, LAS acknowledges that, had the correct information been passed, the focus of Ms Choya’s treatment may have been different.” Source location 2019-0281-Resposne-by-London-Ambulance-Service
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 The existing SBAR handover tool is considered sufficient to help crews convey relevant information to emergency departments, including in stressful circumstances.
Verbatim wording from the response “The LAS currently utilises the SBAR tool for all patient handovers (Situation, Background, Assessment, and Recommendation). This enables crews to be confident that they have passed relevant information onto emergency departments when handing over patients, even in the most stressful scenarios. However, the importance of relaying the important medical information at handover has been stressed to the crew who provided care to Ms Choya, as a part of the feedback and de-brief meetings referred to above.” Source location 2019-0281-Resposne-by-London-Ambulance-Service
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 The emergency department’s treatment decisions are the Whittington Hospital’s responsibility, although LAS measures may support more timely future care.
Verbatim wording from the response “3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.” Source location 2019-0281-Resposne-by-London-Ambulance-Service
Open published response
25 Jun 2019 Robert Cobbina · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to obtain riverfront coastguard location references during emergency calls View source Failure to promptly triage river emergencies and involve appropriate waterborne assets View source
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
Robert Cobbina · 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
Robert Cobbina entered the River Thames on 2 November 2018 and was later retrieved from the river and pronounced dead at the shore. The concerns related to emergency-call handling, including whether callers were prompted to request coastguard or other waterborne assistance and to provide riverfront location references, potentially delaying the deployment of appropriate assets.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain riverfront coastguard location references during emergency calls
Wider context from the report “1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently involve other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or .
2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference .
It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible, and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly triage river emergencies and involve appropriate waterborne assets
Wider context from the report “1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently involve other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or .
2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference.
It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible , and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.
” Open source report
10 May 2019 Karanbir Singh CHEEMA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to transmit allergy action plans to schools View source Lack of standardisation of allergy action plans across hospitals and schools View source Omission of second adrenaline auto-injector guidance from the emergency call algorithm View source Failure to ensure that school medication is in date View source Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement View source Delays in time-critical asthma and allergy review appointments View source Lack of school pupil understanding of allergies and the consequences of allergen exposure View source Failure to check or audit school allergy care plans and medication boxes View source Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure View source Insufficient availability of two adrenaline auto-injectors at all times View source Failure to communicate emergency adrenaline instructions effectively in school staff training View source Absence of emergency adrenaline instructions on EpiPen packaging View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karanbir Singh CHEEMA · 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
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit allergy action plans to schools
Wider context from the report “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school . There is no standardised approach to this , for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardisation of allergy action plans across hospitals and schools
Wider context from the report “4. Allergy action plans are not standardised across hospitals and schools , so messages are not as clearly delivered as they could be . This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of second adrenaline auto-injector guidance from the emergency call algorithm
Wider context from the report “11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given , because this is not contained within the algorithm . That could be remedied internationally.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that school medication is in date
Wider context from the report “3. Karanbir’s EpiPen was out of date . There must be systems in place to ensure that medication in schools is in date .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in time-critical asthma and allergy review appointments
Wider context from the report “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital . By the time of his death four months later he had still not been seen again . There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of school pupil understanding of allergies and the consequences of allergen exposure
Wider context from the report “1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens . Targeted education about this would improve safety.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check or audit school allergy care plans and medication boxes
Wider context from the report “2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately , before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of two adrenaline auto-injectors at all times
Wider context from the report “7. Karanbir had one EpiPen at home, one at school and one at his father’s home . There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate emergency adrenaline instructions effectively in school staff training
Wider context from the report “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency adrenaline instructions on EpiPen packaging
Wider context from the report “9. The EpiPen box does not contain these instructions on the outside .
” Open source report
×
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 Raise the recommendation with IAED-MPDS governance bodies for consideration of a second EpiPen prompt.
Verbatim wording from the response “As you are aware, under the terms of the licence to use MPDS the LAS as a licenced user does not have jurisdiction to make changes to the call taking protocols unilaterally and must submit requests for change to the Standards Committee of the IAED. I am advised by our Chief Medical Officer that this PFD was raised at the UK Clinical Focus Group for IAED-MPDS on 22 May 2019 and has also been raised with the Executive Director of MPDS; ████████ The group welcomed this recommendation and we await their conclusion/outcome.” Source location 2019-0161-Response-Ambulance-Service-NHS-Trust
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 Raise the PFD recommendation with NHS Pathways clinical governance leadership.
Verbatim wording from the response “Our Chief Medical Officer has taken the opportunity to share this PFD with ████████ the Chair for The National Ambulance Service Medical Directors (NASMED) for their consideration who will raise it with the Association of Ambulance Chief Executives (AACE). As the Trust is also a NHS 111 provider for integrated urgent care, this PFD has also been raised with ████████ the Chair of NHS Pathways National Clinical Governance Group and ████████ the NHS Pathways Deputy Clinical Director. ████████ has confirmed that NHS Pathways advises to give another dose if there is no improvement after the first dose and states that “If the individual’s condition does not improve, adrenaline should be repeated if available after 10-15 minutes, according to the manufacturer's instructions”.” Source location 2019-0161-Response-Ambulance-Service-NHS-Trust
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 Share the PFD recommendation with NASMED leadership for consideration and wider ambulance-service escalation.
Verbatim wording from the response “Our Chief Medical Officer has taken the opportunity to share this PFD with ████████ the Chair for The National Ambulance Service Medical Directors (NASMED) for their consideration who will raise it with the Association of Ambulance Chief Executives (AACE). As the Trust is also a NHS 111 provider for integrated urgent care, this PFD has also been raised with ████████ the Chair of NHS Pathways National Clinical Governance Group and ████████ the NHS Pathways Deputy Clinical Director. ████████ has confirmed that NHS Pathways advises to give another dose if there is no improvement after the first dose and states that “If the individual’s condition does not improve, adrenaline should be repeated if available after 10-15 minutes, according to the manufacturer's instructions”.” Source location 2019-0161-Response-Ambulance-Service-NHS-Trust
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 The Trust lacks authority to amend MPDS call-taking protocols unilaterally under its licence.
Verbatim wording from the response “As you are aware, under the terms of the licence to use MPDS the LAS as a licenced user does not have jurisdiction to make changes to the call taking protocols unilaterally and must submit requests for change to the Standards Committee of the IAED. I am advised by our Chief Medical Officer that this PFD was raised at the UK Clinical Focus Group for IAED-MPDS on 22 May 2019 and has also been raised with the Executive Director of MPDS; ████████ The group welcomed this recommendation and we await their conclusion/outcome.” Source location 2019-0161-Response-Ambulance-Service-NHS-Trust
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 Requests to change MPDS call-taking protocols must be submitted to the IAED Standards Committee.
Verbatim wording from the response “As you are aware, under the terms of the licence to use MPDS the LAS as a licenced user does not have jurisdiction to make changes to the call taking protocols unilaterally and must submit requests for change to the Standards Committee of the IAED. I am advised by our Chief Medical Officer that this PFD was raised at the UK Clinical Focus Group for IAED-MPDS on 22 May 2019 and has also been raised with the Executive Director of MPDS; ████████ The group welcomed this recommendation and we await their conclusion/outcome.” Source location 2019-0161-Response-Ambulance-Service-NHS-Trust
Open published response
19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 more concerns
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
Kurt Cochran and 5 others · 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
On 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the period.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding attacks .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report
12 Jun 2018 Olive Nutt · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure to return calls within pre-set time guidelines to obtain further medical details View source Failure to make relevant and proper notes of reported symptoms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olive Nutt · 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
Olive Nutt died at home on 29 January 2018 from heart disease, after waiting up to five hours for an LAS attendance. The concerns were that symptoms were not properly recorded, leading to an incorrect priority decision, and that LAS failed to return a call within its own time guidelines.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to return calls within pre-set time guidelines to obtain further medical details
Wider context from the report “2) The LAS breached its own pre-set time guidelines in failing to return a call to the deceased’s home to take further details of her medical conditions .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make relevant and proper notes of reported symptoms
Wider context from the report “1) The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased
” Open source report
×
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 Control Services staff on call handling and MPDS application, including an anonymised learning-from-experience case study.
Verbatim wording from the response “In addition, our most recent Core Skills Refresher course for Control Services staff which began on 2nd August 2018 and will run until the end of March 2019, includes refresher training on call handling and the application of the MPDS protocol. This refresher course will also specifically include an anonymised case study of the issues highlighted in the management of CAD 3620 as a ‘learning from experience’ example. All EMD staff are required to attend the CSR and this case study is designed to provide EMDs with an example of best practice in applying the appropriate protocols when faced with this type of situation, to improve service delivery to patients.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Submit LAS data to the national review of ambulance response priorities, call-backs and safe systems to support improvement and learning.
Verbatim wording from the response “Ambulance Response Times” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Run a specific Clinical Hub recruitment programme to increase the pool of staff trained in Manchester Triage System and Clinical Hub procedures.
Verbatim wording from the response “All staff working on the Clinical Hub are fully trained in the Manchester Triage System and they must undertake a minimum of one shift per month on the Clinical Hub to maintain their licence.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Introduce three additional Clinical Hubs in Kenton, Barking and Croydon to increase flexible Clinical Hub staffing capacity.
Verbatim wording from the response “Expansion of the LAS Clinical Hub” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Continue the operational staff recruitment drive to increase available staffing capacity.
Verbatim wording from the response “The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester Triage System and with specific Clinical Hub training.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Secure funding for additional recruitment to address Clinical Hub and operational staffing pressures.
Verbatim wording from the response “Resourcing is an ongoing challenge for LAS and we continue to work to address this, including securing funding for additional recruitment. I am very sorry that these difficulties resulted in a delay in ringing back Mrs Nutt to undertake a telephone assessment in a timely way.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Reassess minimum Clinical Hub staffing levels in light of the new national response standard and increased demand.
Verbatim wording from the response “For a day shift the minimum staffing level on the Clinical Hub is eleven members of staff, the level set by a matrix devised in 2013. Work is currently being undertaken to reassess the minimum staff levels in light of the changes within the new national response standard (ARP) and given that demand on the service has continued to increase since 2013.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 Introduce a further Clinical Hub in New Malden to expand local Clinical Hub coverage.
Verbatim wording from the response “We are also planning to introduce a further Clinical Hub in New Malden by the end of 2020. This will be a total of six Clinical Hubs for LAS with a view to covering each of our operational sectors.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
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 The national review of ambulance response times and safe call-back systems is led by the Association of Ambulance Chief Executives.
Verbatim wording from the response “I understand you expressed an interest in the response times assigned to call priorities. A national review is currently being undertaken, led by the Association of Ambulance Chief Executives (AACE) in the process of ringing back patients and safe systems and LAS will respond to any actions and outcomes from this. LAS are playing a significant role in this national review by submitting our data which is being used, in conjunction with other ambulance services, to identify areas for improvement and learning and also to identify and promote areas of good practice.” Source location 2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 13 Insufficient first-aid training for staff supervising pupils View source Failure to confirm replacement medication and complete its dose in the action plan View source Provision of inappropriate emergency asthma inhalers without spacers View source Failure to verify school medication directly during medication reviews View source Failure to provide and follow immediate adrenaline auto-injector administration guidance View source Failure of school staff to familiarise themselves with pupils’ care plans View source Failure to identify poor asthma control and excessive inhaler prescribing for specialist review View source Failure to maintain accurate allergy action plans with medication-use instructions View source Failure to include a school representative in medication reviews View source Failure to maintain identical current care-plan copies across care settings View source Emergency-services contact procedures causing avoidable delay View source Failure to provide effective refresher training and information sharing for trained staff View source Lack of follow-up review tracking after replacement medication is requested View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nasar AHMED · 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
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient first-aid training for staff supervising pupils
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained , most notably not the learning assistant who was supervising the IER . She said that she would not have thought of looking for and retrieving his care plan .
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm replacement medication and complete its dose in the action plan
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box . This meant that he also did not complete the action plan with the dose of the relevant medication .
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of inappropriate emergency asthma inhalers without spacers
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler , which I heard from his respiratory consultant is inappropriate for an emergency situation such as this , and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school medication directly during medication reviews
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist .
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and follow immediate adrenaline auto-injector administration guidance
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of school staff to familiarise themselves with pupils’ care plans
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion . The internal exclusion room (IER) supervisor had not done this for the pupils in the IER . Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify poor asthma control and excessive inhaler prescribing for specialist review
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor ; and his GP was prescribing 30 inhalers a year , the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position . For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate allergy action plans with medication-use instructions
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include a school representative in medication reviews
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy .
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain identical current care-plan copies across care settings
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records .
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Emergency-services contact procedures causing avoidable delay
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay .
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective refresher training and information sharing for trained staff
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training . One member of staff did not share with others the fact that Nasar had asked for this asthma pump . Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan .
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up review tracking after replacement medication is requested
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided .
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report
×
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 paramedic did not advise against using the EpiPen; the call was appropriately managed while necessary information was sought.
Verbatim wording from the response “At no point does the paramedic advise the caller not to use an EpiPen.” Source location Response from London Ambulance Service NHS Trust
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 No action will be taken because the call was appropriately managed and the reported advice was not given.
Verbatim wording from the response “It is our conclusion that the call was appropriately managed by the call handler in trying to elicit the necessary information and it is clear from the transcript provided to you that the Clinical Hub paramedic did not advise Bow School not to use the EpiPen.” Source location Response from London Ambulance Service NHS Trust
Open published response
21 Apr 2017 Najeeb Katende · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to cross-check whether a shockable rhythm is present View source Failure to use a defibrillator in AED mode when first attending or when uncertain about heart-rhythm interpretation View source
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
Najeeb Katende · 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
Najeeb Katende collapsed at school while in cardiac arrest and was not defibrillated for about 24 minutes because his initially shockable rhythm was interpreted as non-shockable. He was later defibrillated but died in hospital; the medical cause of death was Sudden Cardiac Death Syndrome. Concerns included the failure to cross-check the rhythm interpretation and the use and interpretation of the defibrillator device.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to cross-check whether a shockable rhythm is present
Wider context from the report “2. Evidence was also given from other Ambulance staff that:
• Despite the presence of other staff between 10.12am and 10.36am, no cross check was made as to whether Najeeb had a shockable rhythm ;
• If an Automated External Defibrillator, such as those used by members of the public had been applied, this would have detected a shockable rhythm and would have proceeded to defibrilate Najeeb.
3. I consider that it would be of great benefit if LAS were to take the following steps, namely training and instruction to staff:
• Actively cross check with another clinician whether a shockable rhythm is present when attending an incident of this sort ;
• Use the defibrillator in AED mode when first attending as a matter of routine, or at the very least if uncertain when interpreting a heart rhythm;
• Further educate on the interpretation of shockable rhythms from readings provided by defibrillator devices.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a defibrillator in AED mode when first attending or when uncertain about heart-rhythm interpretation
Wider context from the report “2. Evidence was also given from other Ambulance staff that:
• Despite the presence of other staff between 10.12am and 10.36am, no cross check was made as to whether Najeeb had a shockable rhythm;
• If an Automated External Defibrillator, such as those used by members of the public had been applied, this would have detected a shockable rhythm and would have proceeded to defibrilate Najeeb.
3. I consider that it would be of great benefit if LAS were to take the following steps, namely training and instruction to staff:
• Actively cross check with another clinician whether a shockable rhythm is present when attending an incident of this sort;
• Use the defibrillator in AED mode when first attending as a matter of routine, or at the very least if uncertain when interpreting a heart rhythm ;
• Further educate on the interpretation of shockable rhythms from readings provided by defibrillator devices.
” Open source report
19 May 2016 Samuel Rodney Darren BLAIR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 16 Failure to refer antidepressant history to a prison GP View source Failure to enter collateral history into the main clinical records View source Failure to record assessment of mood and suicidal thoughts during prison triage View source Failure to assess drug use during prison triage View source Failure to consider continuation of prescribed citalopram View source Failure to record consideration or a management plan for depression View source Delay in providing the ambulance with the prison gate location View source Inconsistent understanding of prison healthcare emergency procedures View source Out-of-date intermediate life support certification View source Delay in emergency nurse attendance at the patient’s side View source Failure to record discussion or a management plan for schizophrenia View source Failure to recognise prior compliant antidepressant treatment View source Restricted immediate access to the emergency defibrillator View source Failure to promptly acknowledge emergency radio calls View source Lack of current mandatory basic life support and first aid training for all prison officers View source Failure to re-check the pulse during resuscitation View source See 13 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
Samuel Rodney Darren BLAIR · 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
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer antidepressant history to a prison GP
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this .
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enter collateral history into the main clinical records
Wider context from the report “2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records , nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record assessment of mood and suicidal thoughts during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug use during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use , nor did she record asking him about his mood or any suicidal thoughts.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider continuation of prescribed citalopram
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription . The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record consideration or a management plan for depression
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression .
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in providing the ambulance with the prison gate location
Wider context from the report “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.
The LAS controller did not ask at the very outset.
The ideal would be for the information to be given at the very beginning of any emergency call .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of prison healthcare emergency procedures
Wider context from the report “9. That nurse gave a description of the code blue and code red system of describing an emergency, that was markedly different from the understanding given by the prison governor and the London Ambulance Service . I heard that the codes blue and red are even described on posters within the prison.
It therefore appears that a nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Out-of-date intermediate life support certification
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse.
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not ; it is currently at least three years out of date .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in emergency nurse attendance at the patient’s side
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control.
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussion or a management plan for schizophrenia
Wider context from the report “3. There is no record from that meeting of any discussion or management plan for Mr Blair’s schizophrenia .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise prior compliant antidepressant treatment
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration .
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Restricted immediate access to the emergency defibrillator
Wider context from the report “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag . He later had to leave Mr Blair to retrieve the defibrillator , because it is stored in the nurses’ room and only nurses have the key .
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly acknowledge emergency radio calls
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control .
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side.
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of current mandatory basic life support and first aid training for all prison officers
Wider context from the report “The prison officers who found Mr Blair hanging did not have current basic life support training and so were not able to commence cardiopulmonary resuscitation (CPR) before the arrival of nurses . One officer tried to take Mr Blair’s pulse, but was unclear about the correct procedure for this .
This is a situation that I have noted before at HMP Pentonville. I have not made a prevention of future deaths report in the past, because I am aware that the fact that there is no mandatory first aid (including CPR) training for all prison officers is a nationally made, resource led decision.
However, it seems to me that you, as the decision maker regarding not providing such training, should be aware of the impact that this may have on the prison population.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to re-check the pulse during resuscitation
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse .
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date.
” Open source report
×
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 requiring emergency medical dispatchers to confirm the HMP Pentonville entrance at the start of each call.
Verbatim wording from the response “I have been assured by ████████, the LAS’s Deputy Director of Operations (Control Services), ████████ that in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
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 Update the Computerised Gazetteer with both HMP Pentonville vehicular entrances and their postal addresses.
Verbatim wording from the response “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
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 Request HMP Pentonville staff to state the required ambulance entrance at the beginning of every 999 call.
Verbatim wording from the response “The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me. In my reply of 13 November 2015 I confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville. Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer, used in the Emergency Operations Control (EOC), to record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal address of both entrances, were added to the Gazetteer. Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use.” Source location 2016-0196-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
6 Apr 2016 Monica Elaine Lewis-Hinds · Prevention of Future Deaths report South London
View report summary
Concerns raised 1 Failure to proactively ask and record the type of fit during triage calls View source
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
Monica Elaine Lewis-Hinds · 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
Monica Elaine Lewis-Hinds suffered a seizure at home after midnight on 16 January 2015 and later suffered a further seizure that led to asphyxia, cardiac arrest and death. The concern was that the ambulance call handler did not ascertain the type of seizure, delaying the response, and that the London Ambulance Service triage protocol did not require this question to be asked in all cases.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively ask and record the type of fit during triage calls
Wider context from the report “The protocol used by the London Ambulance Service for triage calls includes a question about the type of fit, but the question is not posed by the call handler to the caller , and the section is only completed if the caller offers the information . In view of the potential consequences for the patient, this part of the protocol may require amendment, so that the question is put pre-emptively in all cases.
” Open source report
23 Feb 2016 Lisa Margaret DAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to explain the potentially grave consequences of vomiting illness in a person with diabetes to the caller View source Failure to discuss alternative hospital conveyance options with the person arranging care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lisa Margaret DAY · 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
Lisa Margaret Day died from cardiac arrhythmia from hyperkalemia, associated with diabetic ketoacidosis and poorly controlled type I diabetes. An ambulance arrived approximately four and a half hours after first being called, and concerns were raised that the 111 service did not discuss alternative transport with the friend who made the call or explain the grave consequences of vomiting illness in a person with diabetes.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the potentially grave consequences of vomiting illness in a person with diabetes to the caller
Wider context from the report “1. When Ms Day’s friend rang the 111 service on her behalf, the possibility of conveying her to hospital by means other than an ambulance was discussed with her and she declined.
However, it was not discussed with her friend who made the call. He would have been much better placed to organise this and, if he had, it would probably have resulted in life saving hospital treatment.
The potentially very grave consequences of a vomiting illness in a person with diabetes were not explained to him.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss alternative hospital conveyance options with the person arranging care
Wider context from the report “1. When Ms Day’s friend rang the 111 service on her behalf, the possibility of conveying her to hospital by means other than an ambulance was discussed with her and she declined.
However, it was not discussed with her friend who made the call. He would have been much better placed to organise this and, if he had, it would probably have resulted in life saving hospital treatment.
The potentially very grave consequences of a vomiting illness in a person with diabetes were not explained to him.
” Open source report
×
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 Responsibility for the concern about explaining risks and discussing non-ambulance conveyance rests with the London Central and West Unscheduled Care Collaborative and Dr Ladbrooke.
Verbatim wording from the response “I understand that the first concern is a matter for the London Central and West Unscheduled Care Collaborative and that Dr Ladbrooke will be responding.” Source location Lisa-Day-Response2
Open published response
16 Sep 2015 Adil HABIB · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Lack of prison officer training on choking risks during searches and control and restraint View source Lack of prison officer training on choking risks during searches and control and restraint View source Failure to provide the attending ambulance service with the prison gate location View source Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers View source Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons View source Failure of Hotel 7 nurses to respond immediately to every emergency alarm View source See 3 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
Adil HABIB · 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
Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission , and it would be helpful if such training were mandatory and refreshed regularly. I have written to the National Offender Management Service as provider of prison officer training about this but, in addition, I wanted to bring this direct to your attention. It may be some months before there is any change to the national training offered.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the attending ambulance service with the prison gate location
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend . Whilst there is of course an issue for the prison in terms of offering the information , it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise?
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers
Wider context from the report “The prison officer who rang 999 from the control room did not immediately offer the LAS call handler the location of the prison gate to which the ambulance should be driven . I understand that your team has taken steps to remind all officers working in the control room that they must do this. I understand also that your team has an ongoing conversation with London Ambulance Service to enable best care to be given to those in the prison in need of paramedic attention.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons . Perhaps that would be a useful exercise?
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Hotel 7 nurses to respond immediately to every emergency alarm
Wider context from the report “The nurse who was on call as Hotel 7 at the prison did not respond to the emergency alarm that was activated at the start of the control & restraint of Mr Habib, as she should have . Instead, she only responded once a Level 1 emergency was radioed . I appreciate that this nurse no longer works at HMP Pentonville and that your team has taken steps to remind all nurses operating as Hotel 7 of their responsibility to respond to every alarm immediately.
” 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 Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.
Verbatim wording from the response “With the assistance of the National Offender Management Service (NOMS) we have obtained a list of postal addresses for all prisons and young offender institutions in the UK and have been assured that the Local Safer Custody Leads have been asked to contact their respective local Ambulance Service Trusts to advise if there are additional or temporary gates to be used, either on a temporary or longer term basis, to those held by NOMS. We have made contact with the Safer Custody Lead for Greater London and established that aside from HMP Pentonville the thirteen prison and young offender institutions operate with a single vehicle access gate.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
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 Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.
Verbatim wording from the response “The evidence submitted to the Court during the inquest outlined the actions the London Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main postal address in Caledonian Road for HMP Pentonville and the prison officer making the 999 call did not volunteer that a different prison gate was to be used. After being advised that a second gate was operated in Roman Way the address was added to the Gazetteer with accurate GPS information so that when selected, ambulance staff would be guided to the address by satellite navigation.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
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 Request that prison staff state the ambulance access gate at the beginning of emergency calls.
Verbatim wording from the response “Following the inquest HMP Pentonville’s Head of Residence, ████████ has confirmed to the LAS’s Senior Quality Assurance Manager, ████████, that HMP Pentonville will continue to operate two prison gates. We requested that staff at HMP Pentonville are prompted to give the address of the prison gate ambulance staff are to attend at the beginning of the emergency call to the LAS.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
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 Disseminate learning to emergency operations centre staff through the November Control Services Team Talk, requiring confirmation of the prison address to attend.
Verbatim wording from the response “To share the learning about the call to attend Mr Habib with EOC staff, the November Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked staff to confirm the address to attend when taking a call from any prison or young offender institution. Further, as is our practice, a copy of this reply will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors to share our learning with other ambulance services.” Source location 2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
19 Aug 2015 David Anthony SWEENEY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to assign red prioritisation to calls regarding unconscious patients View source Failure to correctly identify unconscious patients during call handling 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
David Anthony SWEENEY · 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
David Anthony Sweeney was found unconscious and vomiting after a public call to the London Ambulance Service on 18 April 2015. The call was incorrectly categorised, an ambulance arrived 1 hour 40 minutes later, and Mr Sweeney suffered a cardiac arrest shortly before its arrival; he died a week later from hypoxic brain injury and acute alcohol toxicity. The principal concern was that the call did not receive red prioritisation and that a recurring theme might be emerging in the handling of calls about unconscious patients.
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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign red prioritisation to calls regarding unconscious patients
Wider context from the report “A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.
You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious.
I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients.
” 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 London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly identify unconscious patients during call handling
Wider context from the report “A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.
You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious.
I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients.
” 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