8 Jul 2021 Nadeem Ahmed · Prevention of Future Deaths report East London
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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
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
Circulate the SBAR bulletin to LAS clinical staff, LAA paramedics and operations-centre clinical staff through email, intranet, devices and management communications.
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Action
Incorporate SBAR handover content into LAS Core Skills Refresher training and scenario-based education.
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Action
Prepare and issue a joint Medical Director’s bulletin explaining SBAR handover requirements, information content and practical application.
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Action
Expand use of SBAR handovers when clinicians provide reports requesting additional specialist clinical support.
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Action
Update training for operations-centre clinicians receiving clinical information to prompt an SBAR handover when needed.
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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.
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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's Air Ambulance; 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's Air Ambulance; 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
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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 Circulate the SBAR bulletin to LAS clinical staff, LAA paramedics and operations-centre clinical staff through email, intranet, devices and management communications.
Verbatim wording from the response “The bulletin will be circulated to all LAS clinical staff and LAA paramedics by email and will be available on the LAS intranet ‘The Pulse’ and accessible to staff through their personal issue IPads. The content of the bulletin will also be disseminated at sector level through management team communication. This bulletin will also be shared with clinical staff working within the operations centre including the LAA flight paramedics.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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 SBAR handover content into LAS Core Skills Refresher training and scenario-based education.
Verbatim wording from the response “The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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 Prepare and issue a joint Medical Director’s bulletin explaining SBAR handover requirements, information content and practical application.
Verbatim wording from the response “We recognise the importance of ongoing refresher training to ensure staff are kept up to date and reminded of their training and the expected format and standard for such clinical handovers. To serve as a refresher to clinical staff and a checklist to refer to, a Medical Director’s bulletin has been jointly prepared by the LAS and LAA, attached for your reference. The Bulletin sets out the process for an SBAR clinical handover, the information to be included and practical advice on how to approach the handover to ensure best practice is consistently achieved. The bulletin also includes case study examples to demonstrate how the handover should work in practice.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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 Expand use of SBAR handovers when clinicians provide reports requesting additional specialist clinical support.
Verbatim wording from the response “The SBAR tool was developed by the National Patient Safety Agency. The SBAR handover is designed to provide a structure for passing clinical information which is reproducible and aims to minimise risk of either incomplete information being passed or this being misinterpreted due to the ‘human factors’ experienced in a high pressure clinical situation. To provide further assurance around the information which is passed from clinicians on scene to inform the dispatch of further specialist resources we will expand the use of the SBAR handover tool for use in when such reports are provided. We are absolute that this enhanced process should not delay an early request for assistance where it is immediately apparent that such assistance is required but an SBAR should be provided once an initial assessment has occurred.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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 training for operations-centre clinicians receiving clinical information to prompt an SBAR handover when needed.
Verbatim wording from the response “The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed.” Source location 2021-0232-Response-from-London-Ambulance-Service-NHS-Trust_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations