16 Sep 2025 Mohammed Ismail KHAN · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Lack of mandatory and comprehensive paramedic training in obstetric emergencies View source Failure to adhere to clinical guidance for assessing and managing delayed breech birth View source
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
Mohammed Ismail KHAN · 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
Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.
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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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development .
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course .
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk .
” 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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted .
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course.
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.
” Open source report
Concerns raised 1 Failure to use the approved referral form for psychiatric referrals to MPFT 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
Link the Midlands Partnership Foundation Trust and DQS teams to ensure the latest referral form is uploaded to practice clinical systems.
View source
Action
Upload the correct Midlands Partnership Foundation Trust referral form to all GP practice clinical systems and remove previous versions.
View source
Action
Produce and email all GP practices a standard operating procedure for removing old referral forms and managing updated versions.
View source
Action
Confirm to the CCGs that the correct referral form is available to all GP practices and the old version has been removed.
View source
Action
Develop a governance-approved process across Primary Care, Commissioning and DQS for managing and appropriately updating referral forms.
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AI-generated summary
Gwilym Emrys PRICE · 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
Gwilym Emrys PRICE suffered deteriorating mental health after a physical injury and was found hanging at his home on 25 February 2020; he died later that day in hospital. Shortly before his death, his GP referred him to MPFT without using its approved referral form, which could result in incorrect prioritisation in other 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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use the approved referral form for psychiatric referrals to MPFT
Wider context from the report “shortly prior to his death Emrys was referred by his GP to the Midland Partnership Foundation NHS Trust (MPFT) because of his psychiatric presentation. The GP did not use the type of referral form approved by the MPFT. I understand this has been previously circulated with a request that it is used but this has not yet taken place. I do not believe this affected the treatment that Emrys received but in other case it could lead to referrals being given an incorrect degree of priority .
” 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 Link the Midlands Partnership Foundation Trust and DQS teams to ensure the latest referral form is uploaded to practice clinical systems.
Verbatim wording from the response “1. Clinical Commissioning Group (CCG) to link Midlands Partnership Foundation Team and the DQS Team to ensure the most up to date referral form is uploaded onto the practice clinical systems. | ████████ | 28/08/2020 | Complete” Source location 2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
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 Upload the correct Midlands Partnership Foundation Trust referral form to all GP practice clinical systems and remove previous versions.
Verbatim wording from the response “3. DQS Team to upload the correct Midlands Partnership Foundation Trust referral form onto all GP Practice clinical systems and ensure any previous versions are removed. | ████████ ████████ | 09/09/2020 |” Source location 2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
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 Produce and email all GP practices a standard operating procedure for removing old referral forms and managing updated versions.
Verbatim wording from the response “7. CCGs and DQS Team to produce a Standard Operating Procedure (SOP) for removing old referral forms and managing updated versions. This will be emailed out to all GP Practices. | ████████ ████████████ ██████ | 09/09/2020 |” Source location 2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
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 Confirm to the CCGs that the correct referral form is available to all GP practices and the old version has been removed.
Verbatim wording from the response “4. DQS to confirm to the CCGs that the correct referral form is now available to all GP Practices and that the old referral form has been removed. | ████████ ████████ | 09/09/2020 |” Source location 2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
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 Develop a governance-approved process across Primary Care, Commissioning and DQS for managing and appropriately updating referral forms.
Verbatim wording from the response “8. The CCGs to develop a robust process within Primary Care, Commissioning and the DQS Team to ensure referral forms are managed, updated appropriately and approved through governance processes. | ████████████ ██████ ████████ | 30/09/2020 |” Source location 2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Open published response
Concerns raised 3 Lack of an option for paramedics to return deteriorating patients to hospital View source Delays in patient transport home View source Failure to identify deterioration during patient transport 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
Review the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.
View source
Action
Instruct the provider to produce an action plan addressing the identified patient transport safety measures.
View source
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AI-generated summary
Reginald George KEY · 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
Reginald George KEY underwent surgery and was discharged from hospital on 1 December 2016. He was reportedly very unwell when delivered home after a delay in patient transport and was readmitted on 4 December with sepsis. He underwent further procedures and died on 10 December 2016; concerns were raised about his discharge condition, the delay in transport, and whether his deterioration could have been identified or whether paramedics could have returned him to hospital.
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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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an option for paramedics to return deteriorating patients to hospital
Wider context from the report “• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home.
• Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital . He was returned to hospital very unwell on the 4th December 2016.
” 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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in patient transport home
Wider context from the report “• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home .
• Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016.
” 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 NHS Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deterioration during patient transport
Wider context from the report “• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home.
• Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016.
” 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 the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.
Verbatim wording from the response “We have instructed the provider to produce an action plan to address these matters. This plan will be reviewed in detail at the next provider contract and quality meeting in April 2018 by my commissioning and quality teams and will be monitored at this meeting until all actions are concluded and agreed between the provider organisation and the CCGs.” Source location 2018-0025-Response-by-Cannock-Chase-CCG-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 Instruct the provider to produce an action plan addressing the identified patient transport safety measures.
Verbatim wording from the response “Assurances Undertaken to Prevent Future Deaths
To address the Coroner’s concerns we have instructed the provider to act upon the findings and include in their action plan the following:” Source location 2018-0025-Response-by-Cannock-Chase-CCG-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 Hospital transfers requiring escalation are handled by the 999 ambulance service, not patient transport staff.
Verbatim wording from the response “We have discussed the level of skill and escalation procedure with the PTS provider. They have reported all staff are aware of the deteriorating patient policy and they expect staff to enact this when they have any patient concerns. Staff are instructed at times of a medical emergency and/or concerns around the patients’ health, that they are to stop the vehicle and inform the ambulance service of the nature of the emergency and await the service to respond. It is important to highlight that they are not allowed to transport a patient to hospital and are required to seek professional help via the 999 service.” Source location 2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
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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 Transport records contradict the reported four-hour journey and record no observed deterioration or route deviation.
Verbatim wording from the response “17:16 and show that he had been collected by the crew at 17:50. The PTS crew had left the hospital at 18:09 and Mr Key arrived back to his home address in Hednesford at 19:15. We have confirmed that the crew consisted of two patient transport assistants and that these were not paramedics. The PTS service have no record of any concerns being raised by their crew under their deteriorating patient policy and no indication that the crew deviated from the plan as indicated by their transport monitoring system.” Source location 2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
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Request correction
Addressed to NHS Stafford and Surrounds Clinical Commissioning Group, now represented here by NHS Staffordshire and Stoke-on-Trent Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations