6 Jan 2026 Adam Ali Hussain · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS View source Failure to inform waiting families when an ambulance will not be sent View source Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information View source See 2 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.
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AI-generated summary
Adam Ali Hussain · 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
Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.
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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families when an ambulance will not be sent
Wider context from the report “3. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information
Wider context from the report “2. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
” Open source report
5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation View source Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls View source Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Failure to inform waiting families that an ambulance will be sent View source Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service View source See 3 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
Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.
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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls
Wider context from the report “5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call , including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition is reached is for a Category 3 ambulance response
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families that an ambulance will be sent
Wider context from the report “3. Families, waiting for an ambulance response , following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will be sent
” 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 NEMS Community Benefit Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
Wider context from the report “2. There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations