24 Oct 2024 Aran Sean BRADBURY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aran Sean BRADBURY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 21 August 2023, Aran Sean Bradbury applied a ligature to his neck, suffered cardiac arrest and was taken to hospital, where he died on 25 August 2023 from hypoxic ischaemic brain injury following hanging. The report raised concern that ambulance triage coding may assign Category 3 rather than Category 2 priority to patients with a history of mental illness who have ingested substances, potentially resulting in a longer wait for an ambulance. In this case, there was a two-hour delay between the 999 call and ambulance 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 National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code
Wider context from the report “4) I heard oral evidence that: 25-C codes refer to patients with altered levels of consciousness; Code 25-C-1 (which results to a Category 3 prioritisation) refers to patients with an altered level of consciousness and a history of mental illness; Other subsets of Code 25-C exist, including 25-C-2 which refers to patients with an altered level of consciousness who have ingested substances; and that Code 25-C-2 would result to a Category 2 prioritisation.
5) The evidence I heard was that although Mr Bradbury had ingested substances which might have resulted in a 25-C-2 coding (and therefore at Category 2 prioritisation for an ambulance), given that he also had a history of mental illness he was coded as 25-C-1 (and therefore a Category 3 priority) because the system does not allow for consideration of Codes 25-C-2, 25-C-3 etc if it had determined a 25-C-1 code based on the information provided .
6) The operation of this system as described in the evidence I heard could result in patients who might otherwise warrant a category 2 prioritisation being prioritised as Category 3 and therefore wait longer for an ambulance to attend . Patients with a history of mental illness would appear to fall within this group.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England owns 999 call categorisation matters and administers the process for considering proposed changes.
Verbatim wording from the response “In response to your matters of concern around 999 call categorisation, we must inform you that the primary ownership of these matters lie with NHS England. NHS England administer and chair the Clinical Coding Review Group. Any changes to categorisation of calls proposed by this group are then taken to NASMeD for endorsement and are then taken to ECPAG for approval. Once changes” Source location Response from AACE
Open published response
7 Jun 2024 Fern Elisabeth Foster · Prevention of Future Deaths report Buckinghamshire
View report summary
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
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
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.
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 National Ambulance Service Medical Directors; 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 Service Medical Directors; 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
16 Oct 2020 Sarah Fernyhough · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Automatic categorisation of abandoned calls as category 3 View source A ceiling of category 3 for categorisation of all reported medical conditions View source Failure to provide call recordings or full medical information to categorisation decision-makers 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
Sarah Fernyhough · 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
Sarah Fernyhough died at home in the early hours of 22 May 2019 after taking an overdose of venlafaxine, amisulpride and hydroxyzine, as well as cocaine, cannabis and alcohol. The report identified a delay in ambulance attendance and concerns about the categorisation of her call, including the failure to ensure that the relevant call recording or full medical information was reviewed by the person able to upgrade its categorisation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of abandoned calls as category 3
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required .
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation A ceiling of category 3 for categorisation of all reported medical conditions
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure to provide call recordings or full medical information to categorisation decision-makers
Wider context from the report “1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given . Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
” Open source report
27 Jan 2020 Helen Jayne SHEATH · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure to code uncertain self-harm ingestion calls as Category 2 View source Failure to code uncertain self-harm ingestion calls as Category 2 View source Failure to maintain timely availability of a double staffed ambulance 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
Helen Jayne SHEATH · 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
Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.
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 National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure to code uncertain self-harm ingestion calls as Category 2
Wider context from the report “(1) Helen’s father first called ambulance services at 18.20 hours on 2018 which was before he had ingested the sodium nitrate. EAS’s investigation report stated that “from the information provided on this call, that Helen had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled “Psychiatric/Abnormal Behaviour/Suicide Attempt” and the call was coded as a Category 3 . This call has been audited by the Quality Assurance Team and was correctly coded and the correct set of questions used” …yet a Category 3 call is for patients who have potentially urgent conditions that are not life threatening and yet Helen had a history of suicide ideation and her father was unable to tell, being the other side of the locked door, whether the substance had been taken or not. In view of both Helen’s past medical history and the fact that her father had no knowledge as to whether the substance had been ingested or not at that stage, it seemed to the Court that an assumption that an overdose had been taken ought to have been made and this first call, therefore, coded as a Category 2 ;
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure to code uncertain self-harm ingestion calls as Category 2
Wider context from the report “(3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely availability of a double staffed ambulance
Wider context from the report “(2) Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call and it was only after a second call was made to ambulance services at 18.48 hours, when the call handler selected the set of questions titled “Overdose/Poisoning/Ingestion” because it was said that it was suggested on this call that she had ingested the substance that the call was coded a Category 2 and that, due to the lack of DSA availability , at 18.57 hours a Rapid Response Vehicle (RRV) was dispatched with the Mental Health Street Triage Team who arrived at 19.05 and 19.11 hours respectively with a different DSA arriving at 19.25 hours.
” Open source report
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 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
Douglas Paul Oak · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.
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 National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Absence of Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
24 Jul 2019 Maureen Woods · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event View source Insufficient resources for triage of all non-category 1 emergency calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maureen Woods · 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
Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.
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 National Ambulance Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event
Wider context from the report “(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times.
(2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response. However, resources do not permit each and every call to be triaged, and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need .
” 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 Service Medical Directors; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for triage of all non-category 1 emergency calls
Wider context from the report “(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times.
(2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response . However, resources do not permit each and every call to be triaged , and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations