21 Jul 2015 Anne Wilson · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Lack of checklist or question examples for eliciting sufficient welfare concern information View source Lack of guidance on updating involved parties about changes in MPS actions View source Failure to inform the GP when a welfare check request is downgraded View source Lack of guidance on managing additional information received after welfare check closure View source Failure to share the GP’s mobile telephone number with the London Ambulance Service View source Failure to share the final MPS Welfare Check policy with the London Ambulance Service View source Unclear version control for the MPS Welfare Check policy View source Failure of the MPS and LAS to meet to discuss joint working under the welfare checks policy View source Failure to share welfare check policy changes with the London Ambulance Service View source Lack of training for staff handling welfare check requests in the new policy View source Failure to seek further clarification of the GP’s concerns before downgrading a welfare check request View source Lack of guidance on managing welfare checks concerning an individual’s mental health View source See 9 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
Anne Wilson · 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
Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.
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 checklist or question examples for eliciting sufficient welfare concern information
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” 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 updating involved parties about changes in MPS actions
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” 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 when a welfare check request is downgraded
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns.
” 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 managing additional information received after welfare check closure
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed .
(d) The importance of updating those involved in the change in actions being taken by the MPS
” 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 share the GP’s mobile telephone number with the London Ambulance Service
Wider context from the report “(5) The MPS did not share the G.P’s mobile telephone number with the LAS causing delay making further contact with the G.P.
” 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 share the final MPS Welfare Check policy with the London Ambulance Service
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so .
” 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 Unclear version control for the MPS Welfare Check policy
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so.
” 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 MPS and LAS to meet to discuss joint working under the welfare checks policy
Wider context from the report “(7) The MPS and LAS have joint working arrangements but have yet to meet to discuss joint working arrangements under the MPS Welfare checks policy .
” 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 share welfare check policy changes with the London Ambulance Service
Wider context from the report “(1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that 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 Lack of training for staff handling welfare check requests in the new policy
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” 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 seek further clarification of the GP’s concerns before downgrading a welfare check request
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns .
” 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 managing welfare checks concerning an individual’s mental health
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and clarify joint LAS/MPS meeting arrangements to strengthen governance and ensure appropriate LAS representation.
Verbatim wording from the response “Following this Regulation 28 Report, the Director of Operations, who is the Trust's strategic operational lead for joint LAS and MPS working and the Director of Nursing and Quality, who is responsible for strategic policy and liaison regarding mental health and safeguarding with the MPS, have asked for our joint meeting arrangements to be reviewed and clarified to ensure that the governance arrangements are robust and that the LAS is represented at an appropriate level in the future.” Source location 2015-0293-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 Incorporate the March 2015 Metropolitan Police welfare-check policy into the LAS/MPS Joint Memorandum of Understanding through the annual review process.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-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 Provide the current Metropolitan Police welfare-check briefing note to address uncertainty about the policy version in force.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-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 Discuss the welfare-check policy and its impact for ambulance services at the next LAS/MPS Joint Working Group meeting.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The March 2015 Metropolitan Police welfare-check briefing is understood to be the current version in force.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
27 May 2015 Yusuf ABDISMAD · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance View source Failure to use a clear method for establishing whether a patient is conscious or unconscious View source Insufficient training of 111 call handlers in recognising agonal breathing 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
Yusuf ABDISMAD · 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
Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.
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 of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance
Wider context from the report “During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further.
Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent.
” 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 clear method for establishing whether a patient is conscious or unconscious
Wider context from the report “In attempting to gain an answer to the question, “Is the patient awake (conscious)?”, the emergency medical dispatcher first asked “Is Yusuf awake?” When Yusuf’s mother replied “no”, the EMD went on to ask “Is he conscious?”
This seems a confusing way of approaching this very important question. If a person is asleep, then one cannot know if they are conscious without waking them. If the answer to the question “Is he awake?” is “no”, then the most obvious follow up to that would appear to be, “Can you wake him?”
Yusuf’s mother was by now panicking and erroneously replied “yes” to the question of whether Yusuf was conscious, though she had not tried to wake him. The EMD assumed that Yusuf was asleep but rousable, which in fact is unlikely to have been the case.
There were other difficulties with the call, such as the EMD’s failure to recognise that a description of scratches all over might actually refer to a rash, missing the description of pupils no longer visible, and not thinking about the possibility of meningitis. These have, I was told at inquest, been addressed by training, but I remain concerned that such a method of attempting to elicit whether the patient is conscious or unconscious might be used by other EMDs.
” 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 training of 111 call handlers in recognising agonal breathing
Wider context from the report “During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further.
Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing . I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent.
” Open source report
30 Mar 2015 Sabrina Stevenson · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Variation in paramedic training View source Failure to implement or consider automated call recategorisation View source Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues View source Failure to provide call-handlers with feedback on current time-frames View source Failure to address increasing ambulance response times View source Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain View source Insufficient availability of trained paramedics due to vacant positions View source Shortfalls in the ability to undertake internal investigations View source Failure of pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain View source Insufficient crew knowledge of alternative patient extraction techniques View source Failure to progress a pre-hospital validated early warning score system View source Failure to implement or consider clinical re-triaging View source Failure to address increasing ambulance response times View source Lack of steps to take forward a pre-hospital validated early warning score system View source Unaddressed ambulance service staffing vacancies View source See 12 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
Sabrina Stevenson · 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
Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.
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 Variation in paramedic training
Wider context from the report “(3) A related issue was raised at the inquest, regarding whether the increasingly complex clinical role of paramedics means that they should be recruited through graduate, rather than vocational schemes. I am sufficiently concerned by the apparent variation in training that I consider this issue to warrant consideration;
” 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 implement or consider automated call recategorisation
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation , clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points , I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed ;
” 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 call-handlers with feedback on current time-frames
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.
” 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 Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain
Wider context from the report “(4) Concern has been raised by Sabrina’s family, with whom I concur, that the Manchester Triage System should reflect the evidence of the consultant Gynaecologist ; that any woman of child-bearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing .
” 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 trained paramedics due to vacant positions
Wider context from the report “(2) I am concerned by evidence provided from LAS that there are 400 vacant positions within the Trust . This connotes a significant recruitment issue for the profession , which could risk future deaths occurring simply through a lack of available trained paramedics ;
” 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 Shortfalls in the ability to undertake internal investigations
Wider context from the report “(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations . Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain . It is clear that the Trust are taking further steps to address this; however, more detailed information as to time-frames and progress in this regard are required.
” 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 pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene ;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed;
” 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 crew knowledge of alternative patient extraction techniques
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance ;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed;
” 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 progress a pre-hospital validated early warning score system
Wider context from the report “(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view ;
” 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 implement or consider clinical re-triaging
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” 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 address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.
” 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 steps to take forward a pre-hospital validated early warning score system
Wider context from the report “(1) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view and I believe that the College of Paramedics may be in a position to assist in this 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 Unaddressed ambulance service staffing vacancies
Wider context from the report “(2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions , without further detail as to what steps are being taken to address this shortfall ;
” 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 Reduce unnecessary multiple-vehicle dispatches through the agreed change programme.
Verbatim wording from the response “A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.” Source location 2015-0126-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 Invest in new ambulance vehicles to increase operational capacity.
Verbatim wording from the response “The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff re-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals.” Source location 2015-0126-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 Assess the clinical appropriateness and feasibility of automated call re-categorisation.
Verbatim wording from the response “The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.” Source location 2015-0126-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 Keep more ambulances operational and out of workshops through the agreed change programme.
Verbatim wording from the response “A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.” Source location 2015-0126-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 Operate the updated Serious Incident Policy and Procedure with board-to-management responsibilities for reporting, investigation and recurrence-risk reduction.
Verbatim wording from the response “The governance processes relating to serious incident investigations are outlined in the Serious Incident Policy and Procedure, TP/006 most recently updated on 1 April 2015. The Serious Incident Policy and Procedure sets out the responsibilities from the Trust Board, to the Quality Governance Committee, individual directors and senior managers, and management groups in the LAS, as well as and all members of staff for reporting incidents, for investigating serious incidents, and taking action to reduce the risk of recurrence and / or mitigate the harm that may be caused.” Source location 2015-0126-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 Monitor investigation timeliness and obtain assurance that serious-incident investigations are thorough and appropriately approved.
Verbatim wording from the response “The Quality Governance Committee, which meets quarterly, has had and will continue to have a key role in seeking an assurance that the processes in the Serious Incident Policy and Procedure are being complied with and are robust; that incidents are being reported appropriately and identified as serious incidents; that when serious incidents are declared by the Serious Incident Group the root causes are identified and investigated; that lessons are being learned and actions are monitored and completed.” Source location 2015-0126-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 Recruit 850 staff, including approximately 150 new posts, to increase staffing and capacity.
Verbatim wording from the response “The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff re-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals.” Source location 2015-0126-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 Deliver the mandatory Core Skills refresher case-study training on ectopic pregnancy, hypovolaemia and fluctuating capacity to remaining operational staff.
Verbatim wording from the response “A copy of the case study entitled “Learning from Experience” in the mandatory Core Skills refresher training programme 2015. 1 is attached. The case study covers ectopic pregnancy, hypovolaemia, and fluctuating capacity. Also attached is a copy of the achievement record identifying the learner outcomes and objectives completed by the tutor and “student”. As at the 19 May 2015 347 staff (11% of operational staff) had completed the Core Skills refresher training programme, and the remainder of operational staff are expected to complete their training by 3 July 2015.” Source location 2015-0126-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 Issue a clinical bulletin reminding staff about alternative methods and resources for moving patients from scenes.
Verbatim wording from the response “The advice from the Medical Directorate in the Clinical Routine Information Bulletin to be issued on 26 May 2015 to all staff is given below.” Source location 2015-0126-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 Review the feasibility and suitability of providing call handlers with real-time patient waiting-time information.
Verbatim wording from the response “The LAS has considered a facility whereby call handlers have real-time information relating to current waiting times for patients. This process is currently being reviewed by the Management Information and Governance Committees within the Trust for accuracy, appropriateness and suitability in a dynamically fast changing environment. It is essential that this is given careful consideration so that the most accurate information is passed on to patients, without having any detrimental impact on them, their carers or their 3rd party informants.” Source location 2015-0126-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 Review the possibility of introducing a pre-hospital early warning score system in London.
Verbatim wording from the response “As with the introduction of pregnancy testing the Medical Director sought the views of National Ambulance Service Medical Directors’ Group (NASMeD) at their meeting on 21 April 2015 on the use of a national early warning score (NEWS) system in the pre-hospital environment to inform our assessment of the feasibility of introducing an early warning score” Source location 2015-0126-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 Develop a non-emergency patient transport service for patients who do not need immediate clinical treatment.
Verbatim wording from the response “A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.” Source location 2015-0126-Response-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 Automated call recategorisation could increase risk by causing inappropriate ambulance dispatches and reducing protection for patients requiring eight-minute responses.
Verbatim wording from the response “The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.” Source location 2015-0126-Response-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 Immediate pre-hospital pregnancy testing cannot be introduced because training, quality assurance, infection control, waste disposal and patient-management difficulties are significant.
Verbatim wording from the response “After careful consideration of the Consultant Midwife’s clinical opinion, the feedback from other ambulance services, and mindful of the potential impact on response times and the capacity to undertake the necessary training, the Medical Director of the LAS concluded that in the immediate future the LAS would not be in a position to introduce pregnancy testing. Providing appropriate training, quality assurance, infection control and disposal of body waste would present significant difficulty if pregnancy testing was introduced in the pre-hospital setting. Further the management of the patient who was unexpectedly found to have a positive pregnancy test was currently outside of the practice of a paramedic; conversely some patients may be given false reassurance from a negative test.” Source location 2015-0126-Response-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 Existing clinical hub staffing, standard operating procedures and surge-management processes are considered sufficient, removing the need for automated call-handling processes.
Verbatim wording from the response “The Clinical Hub has refined and developed its processes, skill mix and staffing levels since its inception on 2 December 2013 and an increased level of staffing within the Clinical Hub in the Emergency Operations Centres has negated the need for any automated processes. Staff have clear standard operating procedures in place for the management of Held call, vulnerable patients and calls being held awaiting assessment. The demand management plan itself has been reviewed and replaced with the surge management plan, which has a number of criteria for allowing progression through the plan and a scored matrix to evidence and inform any decision made.” Source location 2015-0126-Response-by-London-Ambulance-Service
Open published response
31 Jul 2014 Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure of MPDS to ask whether an overdose patient is alone View source Failure to include methadone among MPDS drug choices following an overdose View source Failure to take appropriate action after unanswered welfare-check callbacks View source Delays in paramedic response to intentional methadone overdose calls View source See 1 more concern
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
Toni Elizabeth SKILLINGTON · 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
Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.
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 of MPDS to ask whether an overdose patient is alone
Wider context from the report “2. The MPDS does not ask specifically whether the patient is alone , though it is recognised that this renders a patient particularly vulnerable. I understand that the LAS has also written to the National Academy for Emergency Medical Dispatch about 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 include methadone among MPDS drug choices following an overdose
Wider context from the report “1. The Medical Priority Dispatch System (MPDS) does not include methadone as a one of the drug choices following an overdose , despite the fact that it is commonly taken in excess. I understand that the LAS has written to the National Academy for Emergency Medical Dispatch about 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 take appropriate action after unanswered welfare-check callbacks
Wider context from the report “3. Two welfare checks were made via ring backs without any reply gained, yet neither of these was followed by the appropriate action . Even accepting how busy and under staffed the service was that night, a call child at least have been made to the police asking for attendance.
” 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 paramedic response to intentional methadone overdose calls
Wider context from the report “4. London Ambulance Service received a call describing an intentional methadone overdose, teath with alcohol, and yet no paramedic responded until three hours later .
” Open source report
8 May 2014 Rajesh Parkash · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Inadequate communications between the London Ambulance Service and neighbouring ambulance services View source Limitation of supervising paramedic oversight to clinical decisions View source Lack of regular ongoing driver training beyond the statutory five-year assessment View source Inadequate communications between the control room and ambulance personnel answering a call View source Lack of a minimum experience requirement for supervising paramedics View source Failure to ensure timely staff awareness of Routine Information Bulletin updates and bulletins View source Failure of staff to understand that motorway driving measures and restrictions apply to all multi-lane highways View source See 4 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
Rajesh Parkash · 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
Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.
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 Inadequate communications between the London Ambulance Service and neighbouring ambulance services
Wider context from the report “7. Action is required to improve communications between the London Ambulance Service and those ambulance services which border its area , such as the South East Coast Ambulance Service.
” 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 Limitation of supervising paramedic oversight to clinical decisions
Wider context from the report “3. Consideration should be given to ensuring that the role of a supervising paramedic extends to all aspects of their work, including driving, and is not limited to clinical decisions .
” 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 ongoing driver training beyond the statutory five-year assessment
Wider context from the report “5. Consideration should be given to providing to all relevant staff regular, on-going driver training over and above the anticipated statutory requirement for a five year assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communications between the control room and ambulance personnel answering a call
Wider context from the report “6. Action is required to improve communications between the control room and the personnel within an ambulance that is answering a call .
” 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 minimum experience requirement for supervising paramedics
Wider context from the report “4. Consideration should be given to imposing some form of minimum experience requirement before a paramedic is able to act in the role of a supervising paramedic .
” 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 timely staff awareness of Routine Information Bulletin updates and bulletins
Wider context from the report “1. Action is required to ensure that ALL updates and bulletins advertised on the Routine Information Bulletin are seen and read by all relevant members of staff in a timely manner .
” 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 staff to understand that motorway driving measures and restrictions apply to all multi-lane highways
Wider context from the report “2. Action is required to ensure that all relevant staff fully understand that the measures and restrictions included in the Trust’s training and guidance that apply to motorway driving apply equally to ALL multi-lane highways regardless of their designation .
” Open source report
21 Oct 2013 Mark Stephen Smith · Prevention of Future Deaths report North London
View report summary
Concerns raised 2 Lack of guidance defining “where possible” in OP060 View source Lack of guidance on supervisor consultation before ending a call with an alone person who has taken an intentional overdose 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
Mark Stephen Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Stephen Smith died after intentionally taking an overdose of medication, complicated by ethanol use and underlying health conditions. An ambulance response was delayed, and the report states that this delay was likely to have contributed to his death. The substantive concern was whether clearer guidance and possible supervisor consultation were needed when deciding not to remain on the line with a person who had taken an intentional overdose and was alone.
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 guidance defining “where possible” in OP060
Wider context from the report “Consideration to be given to giving guidance on what “where possible” in the terms of the above section of OP060 and whether a supervisor should be consulted before the decision is taken not to stay on the line where a person has taken an intentional overdose and is alone.
” 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 supervisor consultation before ending a call with an alone person who has taken an intentional overdose
Wider context from the report “Consideration to be given to giving guidance on what “where possible” in the terms of the above section of OP060 and whether a supervisor should be consulted before the decision is taken not to stay on the line where a person has taken an intentional overdose and is alone .
” Open source report
21 Oct 2013 Daniel Maurice McMahon · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Failure to identify difficulties experienced by patients on Section 17 leave View source Failure to stop trains and set signals to danger when an unwell person is trespassing on the line View source Lack of clear guidance on whether lung decompression needles should be used with a valve View source Failure to gather and pass accurate trespasser and track-section location information 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
Daniel Maurice McMahon · 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
Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.
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 identify difficulties experienced by patients on Section 17 leave
Wider context from the report “(2) Department of Health:-
Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up
” 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 stop trains and set signals to danger when an unwell person is trespassing on the line
Wider context from the report “(3) RSSB:-
The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line . (The current position would be to set the signals to caution ).
” 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 guidance on whether lung decompression needles should be used with a valve
Wider context from the report “(4) London Ambulance Service:-
The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve .
” 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 gather and pass accurate trespasser and track-section location information
Wider context from the report “(1) Metropolitan Police :-
That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track . This is in addition to the attendance location and the incident location normally recorded when a 999 call is made.
” 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 Review needle chest decompression practice with an external thoracic-trauma expert and confirm the appropriateness of not using one-way valves.
Verbatim wording from the response “The report brings to my attention your concerns following the evidence of the court appointed expert in relation to the use of bilateral needle chest decompressions without a valve. As you will be aware, the LAS had available a senior paramedic prepared and able to give evidence on the issue of needle chest decompressions at the inquest but this witness was not called. The LAS have reviewed the matter and I hope that you find the following explanation helpful:” Source location 2013-0271-Response-R
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 current approach of not using one-way valves for needle chest decompressions is considered appropriate.
Verbatim wording from the response “Both before and after the inquest, this matter has been discussed at some length within the Medical Directorate of the LAS. The Medical Director of the LAS and one of our Senior Paramedics took the opportunity to review our practice with Surgeon Commander Leigh Smith, an extensively published author on needle chest decompression and expert on the management of thoracic trauma, and concluded that the current approach of the LAS (and UK ambulance services) is appropriate in respect of not using one way valves on needle chest decompressions.” Source location 2013-0271-Response-R
Open published response
23 Sep 2013 Michael James SWEENEY · Prevention of Future Deaths report London North (Inner)
View report summary
Concerns raised 2 Reliance on “excited delirium” as an apparent diagnosis risking missed organic causes View source Lack of shared recognition of the term “excited delirium” across emergency services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael James 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
Michael James Sweeney died after taking cocaine and becoming extremely agitated; he was transported to hospital by police after an ambulance was not sent within the target time. He was restrained prone until sedation was effective, then arrested and died less than two hours later. The principal concerns were the inconsistent use and understanding of the term “excited delirium”, the risk of missing other medical causes of extreme agitation, and ambulance-service prioritisation of such emergencies.
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 Reliance on “excited delirium” as an apparent diagnosis risking missed organic causes
Wider context from the report “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country, and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011.
It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.
Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis . Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma.
From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause.
1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”.
2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now.
3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service.
4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately.
” 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 shared recognition of the term “excited delirium” across emergency services
Wider context from the report “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country , and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011 .
It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.
Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis. Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma.
From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause.
1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”.
2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now.
3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service.
4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately.
” 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 terminology and guidance issues through the national Ambulance Service Mental Health Working Group for review.
Verbatim wording from the response “excited delirium, which specifically relates to police incapacitant devices (TASERS). We have raised this issue through the national Ambulance Service Mental Health Working Group, asking them to look both at the appropriate terminology and guidance around the subject matter itself. The national Ambulance Service Mental Health Working Group has confirmed that they will issue a position statement about the use of an appropriate term following a response to their proposal from the Royal College of Psychiatrists.” Source location 2013-0236-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 Educate staff and communicate terminology covering acute behavioural disturbance and excited delirium.
Verbatim wording from the response “The LAS alongside our colleagues in the Police Services in London currently use the term acute behavioural disturbance (ABD) to describe the clinical manifestation of disturbed behavior, which is often associated with recreational drug use and / or some aspects of mental health. The term is described by the Faculty of Forensic and Legal Medicine of the Royal College of Physicians (England) in their helpful guidelines paper dealing with the recognition and treatment of this clinical presentation¹. It is from these guidelines, produced by this leading clinical authority on the subject, that the LAS have taken the view that the term “acute behavioural disturbance” (ABD) is appropriate to describe this group of patients and have used this term in the education of our staff.” Source location 2013-0236-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 Share the response with the Pan-London Emergency Department Consultants Group to disseminate the term acute behavioural disturbance.
Verbatim wording from the response “We recognise that the evidence you heard was that some Emergency Department staff were not familiar with the term ABD and as such we will share this response with the Pan-London Emergency Department Consultants Group in order to disseminate the use of the term ABD to the Emergency Departments in London.” Source location 2013-0236-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 Upgrade police-originated calls involving acute behavioural disturbance, cocaine toxicity or physical restraint to the highest response category.
Verbatim wording from the response “In essence, it is the use of the word “acute” that is felt to be key. Since April 2013 the LAS has been upgrading the triage category (to our highest level of response) of calls from the police where there is information which notes the patient is suffering from acute behavioural disturbance, cocaine toxicity, or is being physically restrained.” Source location 2013-0236-Response-by-London-Ambulance-Service
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The term “extremely agitated” does not adequately describe this presentation and may not prompt an appropriate timely response.
Verbatim wording from the response “On 18th October 2013 at the meeting of the Metropolitan Police Clinical Advisory Group, there was consensus that the term ABD was already in common use by paramedics, Emergency Medical Technicians, police officers and the forensic clinicians. The Group has senior medical and clinical representation from the LAS, the Metropolitan Police Forensic Medical Services, and the Education and Training Departments of both organisations. The group’s view was that to re-educate our staff on the use of a different term would be challenging, and may well present a greater risk by using terminology that the pre hospital multi-disciplinary team may not be familiar with. It was felt that the term “extremely agitated” does not adequately describe this particular clinical presentation, is open to wide interpretation, and would not prompt the appropriate timely response.” Source location 2013-0236-Response-by-London-Ambulance-Service
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Protocols and training will not change to adopt the recommended terminology unless and until it accords with national ambulance-service guidance.
Verbatim wording from the response “The London Ambulance Service NHS Trust (the LAS) remains of the view that ‘acute behavioural disturbance’ is the term that most accurately reflects the presentations of this group of patients as well as being recognised by the appropriate bodies and we do not consider that the recommendation can be agreed unless / until the change in terminology accords with national guidance for UK ambulance services.” Source location 2013-0236-Response-by-London-Ambulance-Service
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations