7 Jun 2024 Fern Elisabeth Foster · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 2 Lack of ambulance carriage of appropriate antidote medication for on-scene administration View source Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment 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. 2
Action
Convene the September Clinical Subgroup to discuss toxicological incidents, methylene blue, methaemoglobinaemia management, and potential expansion of HART carriage or trial activity.
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Action
Collate evidence from HART experience and subject-matter experts, then present a report to NASMeD for consideration and review by NASMeD and AACE/JRCALC.
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AI-generated summary
Fern Elisabeth Foster · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.
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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 National Ambulance Resilience Unit; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance carriage of appropriate antidote medication for on-scene administration
Wider context from the report “(2) The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue) , whilst trialled elsewhere, is not part of regional or national protocol . Swift access to this in circumstances where ████████ is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases.
” 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 National Ambulance Resilience Unit; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment
Wider context from the report “(1) The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of ████████ (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene , which may provide the only likely means of prevention of death where sufficient quantity has been ingested.
” 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 Convene the September Clinical Subgroup to discuss toxicological incidents, methylene blue, methaemoglobinaemia management, and potential expansion of HART carriage or trial activity.
Verbatim wording from the response “The next NARU Clinical Subgroup meeting is scheduled for September 2024, though the exact date is yet to be confirmed.” Source location Response from NARU
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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 Collate evidence from HART experience and subject-matter experts, then present a report to NASMeD for consideration and review by NASMeD and AACE/JRCALC.
Verbatim wording from the response “Experience from this project was received by the NARU Medical Advisor on 16th July 2024. In summary, since July 2020 WMASUFT HART have attended 9 cases of suspected ████████ poisoning. This should be considered in the context of total call volume, representing ~1 in 0.5 million 999 calls. Of those 9 cases:” Source location Response from NARU
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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 Each ambulance Trust, authorised by its Executive Medical Director and Chief Pharmacist, decides which drugs its ambulances carry.
Verbatim wording from the response “The decision as to which drugs each ambulance service carries is taken by that individual NHS ambulance Trust with authorisation from the Executive Medical Director in conjunction with Chief Pharmacist.” Source location Response from NARU
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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 Equipping every ambulance with methylene blue may be prohibitively costly and create substantial storage, equipment and training burdens.
Verbatim wording from the response “The dose required to treat a large adult (100kg) would be 100-200mg. This is a significant amount that will require storage within the ambulance. Given space is limited, we might be faced with decisions as to what would be removed from the ambulance to make room for the methylene blue. Therefore, needing to prioritise the medications carried.” Source location Response from NARU
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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 Mandating methylene blue carriage on frontline ambulances is outside NARU’s authority.
Verbatim wording from the response “Firstly, it must be noted that NARU has no authority to mandate the carriage of any specific drugs, including antidotes, by NHS Ambulance Services. Except for those decided by NHS Resilience (EPRR) as part of the Mass Casualty Vehicles (MCV) which are part of the national interoperable capabilities for emergency preparedness to major incidents.” Source location Response from NARU
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NARU cannot provide guidance on HART carriage until incidence, benefits and costs are better understood through further evidence.
Verbatim wording from the response “The subject of antidotes carried by HART is on the list for discussion at a Clinical Subgroup. The advice from this group will be guided by subject matter experts in toxicology and prehospital care. Methylene blue and the detection and management of methaemoglobinaemia will be one of the topics covered. Until we understand the frequency, potential benefits and costs we will not be able to provide guidance to HART. This could be part of a wider trial across a number of HART units to collate more data on patient benefits.” Source location Response from NARU
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29 Apr 2019 Faye Allen · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Ambiguity in staffing-level guidance for medical-area resources at events 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. 3
Action
Make necessary changes to the guidance following stakeholder consultation.
View source
Action
Draft amendments to clarify emergency-plan guidance and address the report’s specific concerns.
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Action
Complete a national review of emergency-plan guidance, including Annex B provisions.
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AI-generated summary
Faye Allen · 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
Faye Allen became unwell after consuming MDMA at an event on 1 May 2016, went into respiratory arrest while being transported to hospital, and died at Manchester Royal Infirmary on 2 May 2016. The inquest considered concerns that guidance on event medical staffing could be interpreted differently, resulting in substantially varying levels of staff available in medical areas.
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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 National Ambulance Resilience Unit; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in staffing-level guidance for medical-area resources at events
Wider context from the report “During the course of the inquest the issue of the availability of paramedics and other medical assistance was considered. The inquest was referred to the National Ambulance Service Guidance for preparing an Emergency Plan specifically Annex B which feeds into the Purple Guide. The annex and its tables set out staffing levels that are recommended for different event types. However, it became clear during the evidence that the recommended levels of staffing could be interpreted in different ways and that for example first aiders deployed in areas other than the medical cabin area were being counted as part of the resource . This meant that staff directly deployed to deal with medical issues in the medical area could vary widely and be significantly below the numbers set out in the tables .
” 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 Make necessary changes to the guidance following stakeholder consultation.
Verbatim wording from the response “• The next stage will be for that draft text to go out to consultation with relevant stakeholders. We will then make the necessary changes and aim to publish a revised version of the guidance before the end of September 2019.” Source location 2019-0147-Responses
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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 Draft amendments to clarify emergency-plan guidance and address the report’s specific concerns.
Verbatim wording from the response “• My Compliance & Quality Team have drafted a number of amendments to be included within the guidance document to add clarity and address the specific concerns raised within the Regulation 28 report findings.” Source location 2019-0147-Responses
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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 Complete a national review of emergency-plan guidance, including Annex B provisions.
Verbatim wording from the response “To date, the following work has been completed.” Source location 2019-0147-Responses
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations