Concerns raised 1 Limitation of Ambulance Support Practitioners' airway management training to supervised i-gel use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Edie Grace Smart · 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
Edie Grace Smart, aged 13, died in hospital on 28 July 2025 after being rescued from the sea at Whitley Bay four days earlier. Emergency crews struggled to secure her airway, and the first ambulance personnel on scene were Ambulance Support Practitioners who were not permitted to use an i-gel without paramedic supervision. The substantive concern was that Ambulance Support Practitioners may often be first on scene at an out-of-hospital cardiac arrest but are trained to use i-gels only under paramedic supervision.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limitation of Ambulance Support Practitioners' airway management training to supervised i-gel use
Wider context from the report “Ambulance Support Practitioners are often first on scene on an out of hospital cardiac arrest but are only trained to use i gels to secure a patient's airway under the supervision of a paramedic .
” 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 Realign non-registered clinical staff scopes through additional education, training and competency assessments.
Verbatim wording from the response “ASPs are not registered healthcare professionals but are trained, assessed, and authorised to undertake a defined range of clinical interventions within an established scope of practice. The ASP role was formally implemented across NEAS on 01 November 2024. Since its introduction, all relevant non-registered clinical staff have undergone a process of scope-of-practice realignment, supported by additional education, training, and competency assessments, to ensure that they are” Source location Response from North East Ambulance Service
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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 ASP i-gel insertion remains restricted to supervision or direction by a registered healthcare professional because it involves advanced airway risks.
Verbatim wording from the response “For this reason, NEAS’ position remains that ASPs may independently undertake the specified basic airway interventions within their authorised scope of practice, whilst the insertion of an i-gel by an ASP should take place under the supervision or direction of a registered healthcare professional, as, for this take place without such supervision, would present an unacceptable level of additional risk to the patient, and unreasonable clinical expectation on ASPs who are not registered healthcare professionals.” Source location Response from North East Ambulance Service
Open published response
Concerns raised 3 Failure to consider obtaining medical records before assessment or treatment View source Lack of paramedic training on transient stroke symptoms View source Absence of a consent-form prompt to consider obtaining medical records before assessment or treatment View source
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AI-generated summary
Joanna Kowalczyk · 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
Joanna Kowalczyk developed neurological symptoms after chiropractic neck manipulation following an earlier neck injury and hospital attendance, and was later diagnosed with vertebral artery dissection and extensive posterior fossa infarction. She died at Queen Elizabeth Hospital on 19 October 2021. Concerns included a paramedic’s lack of awareness that stroke symptoms can resolve temporarily, and the chiropractor’s failure to obtain medical or hospital records before treatment despite the recent hospital attendance and recommended investigations.
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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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider obtaining medical records before assessment or treatment
Wider context from the report “2. The evidence on behalf of the treating chiropractor was that he did not consider it necessary to request GP records or hospital records, before assessment or treatment despite being informed about the Deceased’s recent hospital attendance, investigation which was recommended, and her discharge against medical advice. Even in the updated consent form I have been provided with, which was designed by the British Chiropractic Association, there is no prompt or question designed for the chiropractor to ask to consider obtaining medical records before assessment or treatment, and when this may be appropriate, and the only reference to medical records is a consent to communicate as deemed necessary for the treatment, and for a report to be sent to the GP after treatment. I am concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic training on transient stroke symptoms
Wider context from the report “1. The evidence from the attending paramedic was that she was not aware that symptoms of a stroke can stop after a short time as clearly set out on NHS website and guidance, and that this was not part of her training . This was directly contrary to the Head of Operations’ evidence that this was part of both paramedic training and annual continuing professional development . This was a concerning feature given the accepted evidence of the time critical period to treat patients with symptoms potentially indicative of stroke.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a consent-form prompt to consider obtaining medical records before assessment or treatment
Wider context from the report “2. The evidence on behalf of the treating chiropractor was that he did not consider it necessary to request GP records or hospital records, before assessment or treatment despite being informed about the Deceased’s recent hospital attendance, investigation which was recommended, and her discharge against medical advice. Even in the updated consent form I have been provided with, which was designed by the British Chiropractic Association, there is no prompt or question designed for the chiropractor to ask to consider obtaining medical records before assessment or treatment, and when this may be appropriate , and the only reference to medical records is a consent to communicate as deemed necessary for the treatment, and for a report to be sent to the GP after treatment. I am concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken.
” 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 Feed back stroke-symptom learning to the attending paramedic.
Verbatim wording from the response “I am aware that evidence from one of the attending Paramedics led you to believe that they were not trained to recognise that symptoms of a stroke could cease after a period of time. This was despite the Head of Operations confirming in evidence that firstly he thought the Paramedic had not understood the question. The evidence provided by the Head of Operations described how Paramedics were trained and that secondly, he would ensure that following the inquest he would feed this back to the Paramedic and send a wider update to the Paramedic cohort at the Trust reminding them of the potential for stroke symptoms to dissipate over time. Further to the conclusion of the inquest the Paramedic took it upon themselves to write a detailed Continuing Professional Development (CPD) piece to demonstrate their understanding of Stroke and Transient Ischaemic Attack (TIA).” Source location Response from North East Ambulance Service
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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 Issue a wider update to paramedics reminding them that stroke symptoms may dissipate over time.
Verbatim wording from the response “I am aware that evidence from one of the attending Paramedics led you to believe that they were not trained to recognise that symptoms of a stroke could cease after a period of time. This was despite the Head of Operations confirming in evidence that firstly he thought the Paramedic had not understood the question. The evidence provided by the Head of Operations described how Paramedics were trained and that secondly, he would ensure that following the inquest he would feed this back to the Paramedic and send a wider update to the Paramedic cohort at the Trust reminding them of the potential for stroke symptoms to dissipate over time. Further to the conclusion of the inquest the Paramedic took it upon themselves to write a detailed Continuing Professional Development (CPD) piece to demonstrate their understanding of Stroke and Transient Ischaemic Attack (TIA).” Source location Response from North East Ambulance Service
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 Paramedics are trained to recognise stroke and TIA symptoms, including symptoms that have resolved before assessment.
Verbatim wording from the response “I am aware that evidence from one of the attending Paramedics led you to believe that they were not trained to recognise that symptoms of a stroke could cease after a period of time. This was despite the Head of Operations confirming in evidence that firstly he thought the Paramedic had not understood the question. The evidence provided by the Head of Operations described how Paramedics were trained and that secondly, he would ensure that following the inquest he would feed this back to the Paramedic and send a wider update to the Paramedic cohort at the Trust reminding them of the potential for stroke symptoms to dissipate over time. Further to the conclusion of the inquest the Paramedic took it upon themselves to write a detailed Continuing Professional Development (CPD) piece to demonstrate their understanding of Stroke and Transient Ischaemic Attack (TIA).” Source location Response from North East Ambulance Service
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 The response addresses only concerns specifically related to NEAS and does not address the concern relating to the General Chiropractic Council.
Verbatim wording from the response “I am aware that the report was also issued to the General Chiropractic Council. We will not address this specific concern and simply respond to that specifically related to NEAS.” Source location Response from North East Ambulance Service
Open published response
13 Aug 2024 Margaret HUNTLEY · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 7 Insufficient awareness of Steroid Emergency Cards View source Insufficient usage of Steroid Emergency Cards View source Lack of Ambulance Service staff understanding of steroid medication importance and required actions View source Failure of GPs to routinely request Ambulance Service health-condition alerts View source Lack of triage guidance for responding when patients report prescribed steroid medication View source Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts View source Lack of triage guidance for establishing detailed steroid prescription information View source See 4 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Margaret HUNTLEY · 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
Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.
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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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage, and awareness, of Steroid Emergency Cards .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient usage of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage , and awareness, of Steroid Emergency Cards .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Ambulance Service staff understanding of steroid medication importance and required actions
Wider context from the report “1. There is a lack of understanding amongst (non-clinical and clinical) Ambulance Service staff as to the importance of steroid medication and the steps to be taken should a patient (a) report that they are prescribed steroid medication and/or (b) present with symptoms potentially consistent with steroid insufficiency/Addison’s Crisis.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to routinely request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s; (b) this action is not routinely being taken by GPs .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for responding when patients report prescribed steroid medication
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s ; (b) this action is not routinely being taken by GPs.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for establishing detailed steroid prescription information
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it ; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication.
” 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 Include the time-critical-medications module in statutory and mandatory training delivered in 2025/2026.
Verbatim wording from the response “▪ We have commenced the development of a training module on time critical medications (which will include Steroids) in our Statutory and Mandatory Training module. This will be included in the Statutory and Mandatory training delivered in 2025/2026.” Source location Response from NE Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an Addison’s Self Help Group website link and conduct social-media awareness activity about steroid emergency cards.
Verbatim wording from the response “To ensure consistency with existing public messaging we have included a link to the Addisons Self Help Group website on the NEAS website and have undertaken an awareness campaign via our social media platforms.” Source location Response from NE Ambulance Service
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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 and deliver education materials on steroid-dependent patients and adrenal insufficiency, including two clinical alerts.
Verbatim wording from the response “As well as the above several articles and education package have been developed and delivered within the NEAS. These include 2 clinical alerts, which are the primary way NEAS cascades information to its operational teams on matters of clinical practice:” Source location Response from NE Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate an adrenal-crisis training event and additional adrenal-insufficiency and steroid-dependency resources through corporate communications channels.
Verbatim wording from the response “NEAS will, as part of the learning from this tragic event, provide more educational opportunities for its staff including the following:” Source location Response from NE Ambulance Service
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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 time-critical-medications training module, including steroids, for statutory and mandatory training.
Verbatim wording from the response “▪ We have commenced the development of a training module on time critical medications (which will include Steroids) in our Statutory and Mandatory Training module. This will be included in the Statutory and Mandatory training delivered in 2025/2026.” Source location Response from NE Ambulance Service
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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 Roll out a refresher bulletin for Health Advisors on adrenal insufficiency, Addison’s disease and adrenal crisis, and monitor staff completion and understanding.
Verbatim wording from the response “The current version of NHS Pathways does include supporting information for Health Advisors, in respect to adrenal insufficiency, however we do recognise that Health Advisors may benefit from further information about Addison’s disease and specifically adrenal crisis. We are therefore in the process of rolling out a refresher training bulletin confirming the steps to take in these circumstances with some further information relating to the condition. This will be monitored to ensure it has been read and understood by all Health Advisors and those who receive calls via the 111 and/or 999 services. Linking with my response to your second concern, we will support any changes made in the NHS Pathways system alongside any requirements to provide additional information, instruction or training to our call handling teams.” Source location Response from NE Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NEAS has limited ability to change NHS Pathways and defers the specific triage concern to NHS England, which delivers the system.
Verbatim wording from the response “The system is owned by the Department for Health and Social Care and delivered by the Transformation Directorate of NHS England. NEAS, as a service commissioned by NHS England and other system suppliers enter into licences with the Secretary of State for Health and Social Care, allowing them to embed NHS Pathways within their products. The system is maintained by a group of experienced staff most with an urgent and emergency care background. All the clinical authoring team are registered, licensed practitioners.” Source location Response from NE Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NEAS cannot implement medication-detail questioning in NHS Pathways because it is a national system and recording errors could create additional risks.
Verbatim wording from the response “Due to the fact NHS Pathways is a national system, it is not possible for NEAS to implement a process where Health Advisors will ask the caller to share the details/names of medication, which in turn would need to input as notes for the attending ambulance crew. Based on the rationale above, the vast range of medication would lead onto errors in recording the name of medication and pose additional risks.” Source location Response from NE Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health Advisors are not within the remit to understand complex medical issues such as steroid insufficiency during call triage.
Verbatim wording from the response “Turning towards non-clinical colleagues, specifically Health Advisors, working within the Emergency Operations Centre (EOC) using the NHS Pathways system, currently version 45.2.0. The NHS Pathways system is a national system and has been designed to be used by non-clinicians who ask a series of evidence-based questions to reach an end point. That end point is not a diagnosis, it is just what care and in what timeframe the care is needed. This is then matched to the most appropriate local services who deliver that care. NHS Pathways is not a diagnostic tool, but instead works on the basis of 'ruling out'. This means that questions are asked in order to rule out possible reasons for the patient’s symptoms, until a point where it is safe for the patient to manage their own symptoms with advice or further intervention is needed by a clinician to establish a possible cause.” Source location Response from NE Ambulance Service
Open published response
Concerns raised 1 Failure to make multi-agency familiar face plans easily accessible to ambulance first responders View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sophie Jayne Wilson · 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
Sophie Jayne Wilson was found deceased at home on 2 July 2023 following an overdose, after she had disclosed the overdose to the Crisis team and declined assistance from ambulance responders. The principal concerns were that responders were unaware of her multi-agency familiar face plan and that crucial information about capacity, risk and how to support her was not readily accessible to them.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make multi-agency familiar face plans easily accessible to ambulance first responders
Wider context from the report “(1) Although I received reassurance following the internal investigation that actions have been completed and lessons learnt in relation to this death, I remain concerned about the fact that the ambulance crew and paramedic were entirely unaware of the familiar faces plan in place for Sophie which contained crucially important information pertinent as to how best to assist her, secure her engagement and in relation to issues of both capacity and risk . I was told in evidence that the difficulty related to a data limit upon the electronic devices utilised by NEAS, and that therefore there should be a flag on electronic communications and that the control room would need to be contacted to obtain the additional information. NEAS were a signatory to the multi agency familiar face plan in this case which applies to them as well as a number of other agencies and was designed to assist in supporting the deceased and to reduce the risk of harm.
(2) I am concerned that the information was not seen by the ambulance crew and paramedic who attended , and I am not reassured that it will be available to first responders on future occasions as it seems that the limits of the technology require the ambulance crew or paramedic to spot the flag and to contact the control room, presumably for a verbal account of the information only . I am concerned that in an emergency situation and when services are under such pressure that crucial information, such as a multi agency familiar face plan is not easily accessible to those attempting to offer assistance to some of the most vulnerable people in society.
” 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 Progress supplier consultation and internal governance assessment of proposed technical changes for direct crew access to special patient notes and flags.
Verbatim wording from the response “Linked with these medium-term developments we have already commenced consultation with our software supplier in respect of the feasibility and timescales associated with this development. Initial engagement has been positive, and we have obtained a quote to undertake the technical development work, and a quote has now been obtained with funding identified internally. The changes are currently being considered via internal governance routes to assess potential risks and provide assurances in respect to the impact of the proposed changes. Once the NEAS subject matter expert groups, Change Approval Board and Operational Management Group, have granted approval the Executive Management Group will consider the combined expert opinions and approve the changes.” Source location Response from North East Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade guidance to emergency ambulance crews on accessing additional patient information and using appropriate systems.
Verbatim wording from the response “In respect to access to other clinical records, NEAS ambulance crews also have access to the GP summary information (via GP Connect) and the Great North Care Record, which is a region wide shared care record providing information associated with patients from all providers in the region. Linked with my response to your first concern, I have explained that we have instructed our ambulance dispatch teams to verbally notify staff of any ‘flags’ placed against each case. Alongside this process we will be cascading information to emergency ambulance crews in respect to the importance of accessing additional information and using the appropriate systems.” Source location Response from North East Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ambulance dispatch staff to verbally notify crews of flagged cases and obtain acknowledgement.
Verbatim wording from the response “In considering the fact the ambulance crew were unaware of the familiar faces plan in this case, in respect to terminology we would classify a familiar faces plan within the wider context of a special patient note or a flag. As an interim solution we have instructed our ambulance dispatch team to verbally notify staff of any ‘flags’ placed against each case. This will enable an interaction and to seek an acknowledgement that ambulance crews have seen the ‘flag’ whilst providing an opportunity to share any additional information depending upon the type of ‘flag’.” Source location Response from North East Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an internal task and finish group to assess flag-access processes, explore improvements, and update the existing process.
Verbatim wording from the response “To progress the medium-term improvement work, we have created an internal task and finish group who are tasked with assessing the current process and exploring options to improve the systems and process relating to ‘special patient notes’ or simply ‘flags’ and the ability of ambulance crews to directly access this information. I can confirm that the group held the first meeting on 1st October 2024 with further meetings being scheduled to progress with the outputs from the group. It is important to note that other workstreams are linked with the task and finish group which will help triangulate the wider system improvements I have described.” Source location Response from North East Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regional partners to develop more effective centralised systems for sharing flags and care plans.
Verbatim wording from the response “It is important to mention that both information sharing platforms, GP Connect and Great North Care Record, do not presently have full patient details or care plan documents from all providers. The North East and North Cumbria Integrated Care Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will continue to work with wider system partners to develop more effective centralised means of region wide flagging and care plan sharing.” Source location Response from North East Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The vehicle MDT is unsuitable for receiving or displaying documents because of its purpose and technological limitations.
Verbatim wording from the response “Whilst we are confident that this covers messaging requirements, an additional technical control will be introduced to split any messages into continuation messages should any exceed the specified character limit. In considering the above explanation the MDT within the vehicle is not suitable or an appropriate device to receive documents and/or for crews to use this for reading documentation, given the limitations even with the upgraded technology and software. The MDT serves a specific purpose which is predominately for satellite mapping/navigation and sending critical alerts to staff. We will go onto explain the rationale and our alternative solution to ensure staff have access to additional clinical records and information directly in the response to the second concern.” Source location Response from North East Ambulance Service
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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 The Integrated Care Board is leading regional work to improve centralised flagging and care-plan sharing across providers.
Verbatim wording from the response “It is important to mention that both information sharing platforms, GP Connect and Great North Care Record, do not presently have full patient details or care plan documents from all providers. The North East and North Cumbria Integrated Care Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will continue to work with wider system partners to develop more effective centralised means of region wide flagging and care plan sharing.” Source location Response from North East Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dispatch staff may be unable to contact crews about flags during periods of extreme pressure while balancing other priority communications.
Verbatim wording from the response “It is however important to note that in times of extreme pressure our dispatch staff may not always be able make this contact, whilst balancing other priority contact with crews.” Source location Response from North East Ambulance Service
Open published response
22 Jan 2024 Donna Georgina Smith · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 4 Insufficiently robust methods for detecting worsening conditions in Category 2 calls View source Failure to meet Category 2 ambulance response-time targets View source Failure to detect worsening conditions in Category 2 calls View source Failure to escalate Category 2 calls to Category 1 when conditions worsen View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Donna Georgina Smith · 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
Donna Georgina Smith suffered chest pain at home on 17 July 2021, deteriorated into cardiac arrest, and died shortly after arriving at hospital. The report identifies concerns that her worsening condition was not recognised or escalated from Category 2 to Category 1, that the methods for detecting deterioration were not sufficiently robust, and that the ambulance response took one hour and six minutes.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust methods for detecting worsening conditions in Category 2 calls
Wider context from the report “2. The methods of detecting worsening conditions in existing category 2 calls are not sufficiently robust (dispatch clinician and numerous call condition).
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meet Category 2 ambulance response-time targets
Wider context from the report “3. The category 2 call target (18minute average response and 95ᵗʰ percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect worsening conditions in Category 2 calls
Wider context from the report “1. The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate Category 2 calls to Category 1 when conditions worsen
Wider context from the report “1. The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1 .
” Open source report
×
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 Continue delivering paramedic and Clinical Care Assistant recruitment plans to increase response capacity.
Verbatim wording from the response “The actions to increase capacity update included:” Source location Response from North East Ambulance Service
Open published response
×
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 Establish bi-weekly fleet meetings to oversee vehicle shortages and improve vehicle availability.
Verbatim wording from the response “• Options to extend operating hours within NEASUS and support improved vehicle availability are being reviewed. Bi-weekly operational fleet meeting is now in place to provide clearer oversight and scrutiny to vehicle shortages to enable us to work better with NEASUS and be more proactive in identifying hot spots. (NEASUS is a wholly owned subsidiary of NEAS, providing fleet and other specialist services)” Source location Response from North East Ambulance Service
Open published response
×
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 Implement a one-division eVDI and daily-clean trial with standardised task timing and dispatch alerts.
Verbatim wording from the response “Ongoing work linked with the above includes the following improvements to help maintain resource availability for Category 2 emergency response. NEAS are currently employing the following additional tactics.” Source location Response from North East Ambulance Service
Open published response
×
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 Establish and progress a task-and-finish programme to release operational time and improve downtime management.
Verbatim wording from the response “• Task and Finish group established to focus on releasing time including improvement of processes to manage downtime, system development being progressed to enable auto clear for crews. Individual level reports have been developed to support performance management of downtime. Changes to downtime codes and processes have been developed.” Source location Response from North East Ambulance Service
Open published response
×
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 Operate the Dispatch Clinical Risk Assessment procedure to prioritise Category 2 responses by clinical risk.
Verbatim wording from the response “Dispatch Clinical Risk Assessment Standard Operating Procedure (SOP)” Source location Response from North East Ambulance Service
Open published response
×
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 Finalise the business case for commissioners to consider increased Dispatch resources.
Verbatim wording from the response “In addition to the pressures on our operational crews, the funding request is to help secure further investment into the Dispatch function to reduce the chance of missed opportunities to dispatch an ambulance to patients most in need. As demand for NEAS services has grown, increasing numbers of patients remain on the Dispatch Stack. With workloads on each Dispatch desk growing, NEAS commissioned independent reviews by the Association of Ambulance Chief Executives and Operational Research in Health (ORH). The evidence from these reviews shows that each Dispatch desk has more resources than would be considered appropriate to achieve optimum performance with the resources available. A business case is being finalised for commissioners to consider as part of the 2024/2025 planning rounds.” Source location Response from North East Ambulance Service
Open published response
×
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 Finalise the EOC clinician procedure for managing deteriorating patients.
Verbatim wording from the response “Whilst not directly linked with this case, we are writing a procedure for EOC clinicians to provide guidance for deteriorating patients. The procedure is not yet finalised given the complexities and balance of not overwhelming the system with higher priority ambulance responses. The risk with the latter is that we would create potential risk for patients categorised as Category 2 and Category 3, ultimately leading to delayed responses. The underpinning principles are those achieved by using the NHS Pathways system and/or other algorithm-based triage tools and achieving the Ambulance Response Programme response targets.” Source location Response from North East Ambulance Service
Open published response
×
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 Implement handover escalation, navigation and liaison measures to mitigate ambulance handover delays.
Verbatim wording from the response “• The Trust continues to work with the ICB to support the wider system delivery of handover improvement. Additional system actions have been implemented to mitigate impact of handover times including: 2-hour handover reporting to Directors on-call, with 3-hour handovers escalated to ICB strategic on-call; Paramedic and Nurse Emergency Department navigators in place in 4 locations; Hospital Ambulance Liaison Officers (HALO) in place at James Cook. Development of immediate handover proposal is being progressed as part of C2 extremis actions.” Source location Response from North East Ambulance Service
Open published response
×
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 Improve Patient Transport Service staffing and resources for urgent, low-acuity and weekend demand.
Verbatim wording from the response “4. Secure additional Patient Transport Service (PTS) support focused on weekends.” Source location Response from North East Ambulance Service
Open published response
×
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 Operate the centralised Operations Co-ordination Centre for time-critical operational matters.
Verbatim wording from the response “• Operations Co-ordination Centre (OCC) is now in place providing a centralised function based on the best practice and learning from other ambulance Trusts. A central point which will manage any time critical matters to ensure consistency and clarity to both internal and external stakeholders.” Source location Response from North East Ambulance Service
Open published response
×
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 Implement staggered crew shifts and third-party bridging shifts to maintain capacity during transitions.
Verbatim wording from the response “Staggered shift start and finish times” Source location Response from North East Ambulance Service
Open published response
×
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 Implement a dedicated dispatcher and coordinate third-party resources for Pass to Patient Transport Service work.
Verbatim wording from the response “1. Dedicated dispatch officer focused on pass to Patient Transport Service calls.” Source location Response from North East Ambulance Service
Open published response
×
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 end-of-shift tasking policy to identify opportunities to improve Category 2 response.
Verbatim wording from the response “7. Review End of Shift tasking.” Source location Response from North East Ambulance Service
Open published response
×
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 Request additional commissioner funding for operational resources and Dispatch investment.
Verbatim wording from the response “On a more general note, the Trust is currently in contract negotiations in respect to funding from our commissioners. We have requested additional funding to enable an increase in resources to help improve service delivery, including improving ambulance response times. I am aware that the contract negotiations include discussions surrounding the wider health and social care system and what other partners can do to assist with easing pressures on the Trust. Factors such as hospital handover delays, availability of other services, demand deflection and inappropriate discharges all create potentially unnecessary demand on the Trust. This is not unique in our region and is a challenge faced by our colleagues in other ambulance services around the country.” Source location Response from North East Ambulance Service
Open published response
×
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 Implement the annual-leave buy-back scheme.
Verbatim wording from the response “• Buy-back scheme for annual leave has been implemented.” Source location Response from North East Ambulance Service
Open published response
×
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 Offer targeted overtime shifts to increase ambulance capacity.
Verbatim wording from the response “• Additional shifts are being offered as overtime to boost capacity, with targeted overtime shifts incentivised over the Christmas period.” Source location Response from North East Ambulance Service
Open published response
×
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 deployment guidance and responses per incident against national benchmarks.
Verbatim wording from the response “3. Review Dispatch Plan on multiple resource assignments.” Source location Response from North East Ambulance Service
Open published response
×
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 Secure and use additional third-party hours funded by NHS England investment.
Verbatim wording from the response “• All additional third-party hours funded by additional NHS England investment have now been secured.” Source location Response from North East Ambulance Service
Open published response
×
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 The call handler followed NHS Pathways correctly, and the patient's conscious, breathing condition did not warrant a Category 1 response.
Verbatim wording from the response “In respect to this concern, the NEAS investigation concluded that the call handler managed the call correctly and followed the NHS Pathways system and generated a Category 2 ambulance response. This is the highest level of response for a patient who is severely unwell but conscious and breathing and in line with the Ambulance Response Programme (ARP).” Source location Response from North East Ambulance Service
Open published response
×
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 Responsibility for changes to NHS Pathways algorithms and system-generated response categories rests with NHS England and the Secretary of State.
Verbatim wording from the response “The system is owned by the Department for Health and Social Care and delivered by the Transformation Directorate of NHS England. NEAS, as a service commissioned by NHS England and host system suppliers enter into licences with the Secretary of State for Health and Social Care, allowing them to embed NHS Pathways within their products. The system is maintained by a group of experienced staff most with an urgent and emergency care background. All the clinical authoring team are registered, licensed practitioners.” Source location Response from North East Ambulance Service
Open published response
×
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 Even with further clinical information, a conscious patient with regular breathing would not necessarily have warranted a higher-priority Category 1 response.
Verbatim wording from the response “Clinicians working in the Emergency Operations Centre (EOC) have the ability to upgrade a disposition following their clinical assessment, supported by the NHS Pathways system and underpinned by their clinical knowledge. In this case the investigation identified that the clinician had not sufficiently probed the responses provided.” Source location Response from North East Ambulance Service
Open published response
×
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 Some planned improvements to ambulance response performance depend on securing additional funding through forthcoming negotiations.
Verbatim wording from the response “On a more general note, the Trust is currently in contract negotiations in respect to funding from our commissioners. We have requested additional funding to enable an increase in resources to help improve service delivery, including improving ambulance response times. I am aware that the contract negotiations include discussions surrounding the wider health and social care system and what other partners can do to assist with easing pressures on the Trust. Factors such as hospital handover delays, availability of other services, demand deflection and inappropriate discharges all create potentially unnecessary demand on the Trust. This is not unique in our region and is a challenge faced by our colleagues in other ambulance services around the country.” Source location Response from North East Ambulance Service
Open published response
15 Dec 2023 John Robert Taylor · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 5 Failure to adequately check door handles before attempting entry View source Failure of internal investigations to elicit the circumstances of relevant operational failures View source Failure to report relevant operational failure circumstances to the SI author View source Failure to consider alternative transport to hospital View source Failure of the SI to consider relevant operational failure issues View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Robert Taylor · 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
John Robert Taylor took a deliberate insulin overdose and contacted emergency services for help. The ambulance arrived more than 13 hours later, and he died in hospital on 27 July 2022; the inquest concluded that the delay contributed to his death. Concerns included inadequate checking of the property’s unlocked door, the failure to include this issue in the internal investigation, and the lack of consideration of using a taxi to transport him to hospital sooner.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately check door handles before attempting entry
Wider context from the report “1. The attending paramedics had not adequately checked the door handle . It was unlocked. As a result, they waited an extra 30 minutes for the police to arrive in order to gain entry.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to elicit the circumstances of relevant operational failures
Wider context from the report “2. The circumstances surrounding the failure to adequately check the door handle was not offered or elicited within the internal investigation . Subsequently it was not reported to the SI author. This issue was not considered within the SI.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report relevant operational failure circumstances to the SI author
Wider context from the report “2. The circumstances surrounding the failure to adequately check the door handle was not offered or elicited within the internal investigation. Subsequently it was not reported to the SI author . This issue was not considered within the SI.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative transport to hospital
Wider context from the report “3. Consideration was not given to the possibility of sending a taxi to Mr Taylor so he might be conveyed to hospital quickly .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the SI to consider relevant operational failure issues
Wider context from the report “2. The circumstances surrounding the failure to adequately check the door handle was not offered or elicited within the internal investigation. Subsequently it was not reported to the SI author. This issue was not considered within the SI .
” Open source report
×
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 the forcible-entry memorandum of understanding and progress it through partner ratification.
Verbatim wording from the response “In addition to the ongoing efforts to extend the MOU, the Trust have recently, October 2022, provided refresher training to managers within the Emergency Operations Centre (EOC) to ensure that their teams/staff follow the agreed process for cases where forcible entry may be required. This includes the arrangements in place via the MOU and also those areas were the primary support for forcible entry remains with the police. This is certainly the case within Cleveland. I have enclosed a copy of the current version of the MOU for your information, albeit this is not currently within the Cleveland area however the same principles for checking doors, windows and neighbours remain the same for our attending crews in the Cleveland area. There is an update currently being applied to the MOU detailing the improvements to the process which is proceeding through the ratification process.” Source location Response from North East Ambulance Service
Open published response
×
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 Train Emergency Operations Centre managers to oversee reasonable entry attempts before requesting forcible entry assistance.
Verbatim wording from the response “In addition to the ongoing efforts to extend the MOU, the Trust have recently, October 2022, provided refresher training to managers within the Emergency Operations Centre (EOC) to ensure that their teams/staff follow the agreed process for cases where forcible entry may be required. This includes the arrangements in place via the MOU and also those areas were the primary support for forcible entry remains with the police. This is certainly the case within Cleveland. I have enclosed a copy of the current version of the MOU for your information, albeit this is not currently within the Cleveland area however the same principles for checking doors, windows and neighbours remain the same for our attending crews in the Cleveland area. There is an update currently being applied to the MOU detailing the improvements to the process which is proceeding through the ratification process.” Source location Response from North East Ambulance Service
Open published response
×
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 Cascade updated forcible-entry procedures, an operational alert and call-handling guidance to relevant staff.
Verbatim wording from the response “I have enclosed a copy of the updated Standard Operating Procedures (SOPs) for Unscheduled Care Dispatch Staff. The overarching SOPs include an update in relation to forcible entry at pages 83 and 84, plus show the wider processes for completeness. The updated SOPs were cascaded on 4 February 2024. In addition to the SOPs, an Operational Alert has been issued to operational staff, I have enclosed a copy of the alert which was cascaded on 7 February 2024. In addition updated guidance for Call Handling staff was shared on 8 February 2024 which I have enclosed.” Source location Response from North East Ambulance Service
Open published response
×
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 Implement the Emergency Ambulance Response Validation procedure, including welfare-call prioritisation and documented assessment of suitable alternative transport.
Verbatim wording from the response “In relation to the Management of Long Waits Policy, this policy was removed from use on 25 August 2022 and was replaced with the Procedure for Emergency Ambulance Response Validation and was implemented on 25 August 2022. The new procedure provides a process whereby welfare calls are only required to be made to patients who are alone. In these cases, the clinician is required to update the notes to make it clear when viewing the case list whether a welfare call is required or not by documenting ‘welfare’ or ‘no welfare’.” Source location Response from North East Ambulance Service
Open published response
×
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 A taxi was not appropriate because suicidal intent and other red flags made non-clinical transport unsafe.
Verbatim wording from the response “During the inquest you heard verbal evidence from a NEAS Clinical Section Manager who advised that in respect to the call on 18 July 2022, a taxi was not considered and would not have been appropriate given the nature of the call. The review of the clinician’s call undertaken by another Clinical Section Manager, shows that some red flags existed and should have prompted a higher level of caution, therefore the use of a taxi would not be appropriate. This was on the basis that the caller was expressing suicidal intent and plans, therefore not safe or appropriate to send a taxi in these circumstances. We have previously disclosed this report to your office and this was covered during live evidence by the Clinical Section Manager attending the inquest.” Source location Response from North East Ambulance Service
Open published response
×
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 The attending crew did check the door, and the delay arose from a misunderstanding about whether it was already open.
Verbatim wording from the response “In respect to enquiries made since the inquest, we have reviewed the call made to the NEAS Emergency Operations Centre by the attending crew. The call is very clear with a member of the crew clearly explaining the efforts made, including checking the door, knocking on windows/door and shouting through the letter box, which were consistent with the written witness statement. One of my senior leadership team has met the crew and raised the matter in respect to the information provided by the police. The recollection of events from the crew is consistent with their witness statements with both crew members stating they had tried to open the door. This accords with the details passed during the conversation with the NEAS Emergency Operations Centre.” Source location Response from North East Ambulance Service
Open published response
Concerns raised 5 Failure to provide Trust-wide learning and training from serious incidents View source Failure to seek clinical input for mental health-related incidents View source Inadequate Trust policy or protocol for handling mental health-related incidents View source Failure to undertake detailed assessments of mental health-related incidents View source Failure to provide comprehensive retraining for staff directly involved in incidents 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.
×
AI-generated summary
Adam GALLAGHER · 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 Gallagher, aged 30, died on 18 October 2021 after being found at around 9am, following communication of suicidal ideation while under the influence of alcohol. The report identifies a missed opportunity for urgent intervention, including limited assessment, no clinical input and no ambulance dispatch, and raises concerns about learning, retraining and mental-health incident protocols.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Trust-wide learning and training from serious incidents
Wider context from the report “(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have
been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an
alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff
involved.
Serious events of this nature should be subject of Trust wide learning and training to prevent
future deaths.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek clinical input for mental health-related incidents
Wider context from the report “(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have
been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an
alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff
involved.
Serious events of this nature should be subject of Trust wide learning and training to prevent
future deaths.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate Trust policy or protocol for handling mental health-related incidents
Wider context from the report “(3)An urgent review of Trust policy/protocol for handling/management of mental health
related incidents should be undertaken and associated training in respect thereof.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake detailed assessments of mental health-related incidents
Wider context from the report “(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have
been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an
alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff
involved.
Serious events of this nature should be subject of Trust wide learning and training to prevent
future deaths.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide comprehensive retraining for staff directly involved in incidents
Wider context from the report “(2) Comprehensive retraining is required for those directly involved.
” Open source report
Concerns raised 6 Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies View source Failure to identify familial or social support for the patient View source Delays in reacting meaningfully and promptly to presenting danger View source Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation View source Failure to accurately evaluate and grade the presenting danger View source Failure to enquire about the patient’s location and immediately available support 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
MAUREEN WHARTON · 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 Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify familial or social support for the patient
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reacting meaningfully and promptly to presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat . Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately evaluate and grade the presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about the patient’s location and immediately available support
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report
30 Oct 2019 Philip Richard Hayes · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 6 Inconsistency in approach and answers to algorithm questions indicating risk of aortic aneurysm, rupture or dissection View source Triage of calls by health advisors with limited medical training and no medical qualifications View source Inconsistency in referral for clinical input View source Delay in ambulance dispatch View source Insufficient triage by algorithm when inadequate weight is given to reported symptoms and indicators of a medical emergency View source Failure to conduct reassessment of C2 category 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
Philip Richard Hayes · 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
Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based triage.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in approach and answers to algorithm questions indicating risk of aortic aneurysm, rupture or dissection
Wider context from the report “(3) Inconsistency in approach and answers to algorithm question designed
to indicate risk of aortic aneurysm/rupture/dissection
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Triage of calls by health advisors with limited medical training and no medical qualifications
Wider context from the report “(4) Calls triaged by health advisors with limited medical training and no
medical qualifications
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in referral for clinical input
Wider context from the report “(5) Inconsistency in approach to referral for clinical input
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in ambulance dispatch
Wider context from the report “(1) Delay in ambulance dispatch
Call categorised C2 received response 1 hour 2 minutes after
original call
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient triage by algorithm when inadequate weight is given to reported symptoms and indicators of a medical emergency
Wider context from the report “(6) Appropriateness of triage by algorithm. Insufficient if any weight given
to actual reported symptoms and indicators of a medical emergency
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct reassessment of C2 category
Wider context from the report “(2) Failure to conduct reassessment of C2 category notwithstanding 5
subsequent calls describing additional symptoms and a deteriorating
condition
” Open source report
27 Feb 2018 Raymond Henry Davidson (Raymond) · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Insufficient ambulance resources causing delays to urgent responses View source Failure to make direct telephone contact with the patient during initial clinical review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raymond Henry Davidson (Raymond) · 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
Raymond Henry Davidson died at home on 10 June 2017 after ambulance responses to urgent and emergency calls did not attend before he stopped breathing. The report identified ongoing ambulance resource shortages and delays in responding to urgent cases, as well as concerns that the initial clinical review was not sufficiently robust because telephone contact was not made directly with Raymond.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance resources causing delays to urgent responses
Wider context from the report “I heard evidence that: -
• the recruitment/retention of staff had improved; and
• welfare calls triggered earlier clinician involvement than previously; and
• although there were several other initiatives under way, operational shortages were ongoing .
Raymond’s death highlighted resource issues. There was only so much NEAS could do when they simply did not have enough ambulances to send . At times demand was greater than the resources NEAS had available . The effect of urgent cases being interposed put back those cases appearing to be less urgent . In this case: -
• 10 hours 51 minutes elapsed from the original 111 call;
• 8 hours and 29 minutes after the urgent categorisation; and
• 1 hour 3 minutes after the case was prioritised as a G2 response.
This is the third such report about the same issue that I have written in recent months as I consider that there is a risk of future deaths. An urgent review of resources and their application is needed.
Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly, which may have impacted on the less than robust initial clinical review of Raymond’s condition.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct telephone contact with the patient during initial clinical review
Wider context from the report “I heard evidence that: -
• the recruitment/retention of staff had improved; and
• welfare calls triggered earlier clinician involvement than previously; and
• although there were several other initiatives under way, operational shortages were ongoing.
Raymond’s death highlighted resource issues. There was only so much NEAS could do when they simply did not have enough ambulances to send. At times demand was greater than the resources NEAS had available. The effect of urgent cases being interposed put back those cases appearing to be less urgent. In this case: -
• 10 hours 51 minutes elapsed from the original 111 call;
• 8 hours and 29 minutes after the urgent categorisation; and
• 1 hour 3 minutes after the case was prioritised as a G2 response.
This is the third such report about the same issue that I have written in recent months as I consider that there is a risk of future deaths. An urgent review of resources and their application is needed.
Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly , which may have impacted on the less than robust initial clinical review of Raymond’s condition .
” Open source report
×
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 Reduce C2 conveyance rates in Central and North divisions toward South division levels by 2021/22.
Verbatim wording from the response “2. Some reduction in conveyance rates is also feasible, with a corresponding increase in time at scene, particularly in Central and North divisions.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Reduce hospital handover times toward a 30-minute mean in each division by 2018/19.
Verbatim wording from the response “3. A reduction in time at hospital should be targeted, particularly in Central and North divisions, aiming to reduce to a 30-minute mean by 2018/19 in each division.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Establish and operate an implementation group to develop, implement and oversee the detailed ORH implementation plan.
Verbatim wording from the response “The Trust has started to share the content of the ORH report with stakeholders via a number of engagement events. We have established an implementation group who will develop, implement and oversee a detailed implementation plan. This will include current rosters versus new, staffing implications, vehicles and estates. The Trust and partners are reviewing contractual implications alongside the approval processes.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 and approve an action plan with timescales for addressing the funding shortfall and delivering ambulance response standards.
Verbatim wording from the response “– We are aiming to develop and approve an action plan by the end of May 2018 that will include timescales to address the shortfall in funding and deliver the ARP standards;” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Use a regional handover standard operating procedure and task-and-finish collaboration to improve accountability for ambulance handovers.
Verbatim wording from the response “We are working with our partners across the region in a Task and Finish Group to focus on ambulance handovers. We hold a weekly conference call with all of the acute trusts, NHS England, NHS Improvement and the North East Urgent and Emergency Care Network to address issues and formulate strategies to improve handover. We have developed a joint standard operating procedure for handover across the region which has been in place since November. We are working together to ensure that there is a culture of accountability for handover embedded in both the acute and ambulance Trusts at grass roots level. Hospital Handover is part of every individual’s objective and discussed during performance reviews and ride-outs.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Audit dispatch allocation times monthly and provide training or action plans where dispatchers need support.
Verbatim wording from the response “The Dispatch managers monitor on a monthly basis through audit, the allocation times of the dispatch team. The time frames are monitored in line with national guidance to ensure compliance. Individual training and actions plans can and are issued with any dispatcher who needs further support in ensuring calls are allocated within the given dispatch standard times” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Base an operational manager permanently within two acute trusts to monitor, manage and escalate handover issues.
Verbatim wording from the response “We are basing an Operational manager permanently within two acute trusts to monitor and manage the handover process and build relationships within the hospital to ensure that issues are escalated early so we can take proactive action before we start to experience handover delays” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Improve dispatch-team productivity by reducing the number of ambulances managed by each dispatcher.
Verbatim wording from the response “We are working with ORH to look to improve our crew shift start and finish times. This will also assist with better overall availability of crews throughout the shift. We are also looking to improve the productivity of the dispatch teams by reducing the number of ambulances managed by each dispatcher.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Improve crew shift start and finish times to increase crew availability.
Verbatim wording from the response “We are working with ORH to look to improve our crew shift start and finish times. This will also assist with better overall availability of crews throughout the shift. We are also looking to improve the productivity of the dispatch teams by reducing the number of ambulances managed by each dispatcher.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Provide 50 additional E-Care course places to equip staff to leave suitable patients safely at home.
Verbatim wording from the response “We are working with Northumberland CCG to put in place a rapid response team who will provide a multidisciplinary team to respond to a wide range of lower acuity cases in the community to provide paramedics with an alternative option to ED. We have provided 50” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Work with Northumberland CCG to establish a multidisciplinary rapid response team for lower-acuity community cases.
Verbatim wording from the response “We are working with Northumberland CCG to put in place a rapid response team who will provide a multidisciplinary team to respond to a wide range of lower acuity cases in the community to provide paramedics with an alternative option to ED. We have provided 50” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Implement the REAP and Escalation Policy defining actions for Emergency Operations Centre and operational staff in response to demand.
Verbatim wording from the response “The Trust has also implemented a robust REAP / Escalation Policy which details very clearly the actions to be taken within the Emergency Operations Centre and by Operational staff in line with demand.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Implement the updated Urgent Ringback Procedure, prioritising direct conversation with patients wherever possible, and communicate it to relevant staff.
Verbatim wording from the response “I can confirm that the updated ‘Urgent Ringback Procedure’ was approved and implemented in February 2018. The updated procedure is available and communicated onto all Call Handlers, Clinicians and Team Leaders within the Trusts Emergency Operations Centre. The new procedure puts the emphasis on direct conversation with the patient wherever possible. In relation to the 111 Clinician, the individual was provided one-to-one feedback on this case and undertook a coaching session.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Achieve a 25% frontline-staff abstraction target through a 33.3% relief rate and associated workforce efficiency.
Verbatim wording from the response “– Within this agreement, an assumption is made in the ORH report that abstraction rates of frontline staff are reduced from 34.4%. A target abstraction level of 25%,” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Commissioners control withdrawal of £1.3 million from the emergency operations centre and will address resulting safety concerns after NHS111 procurement.
Verbatim wording from the response “Separately, we have raised a significant patient safety concern with commissioners over their decision to withdraw £1.3 million from our 999 emergency operations centre by September 2018. This removes a significant number of clinical support advisers to our 999 call takers and dispatchers. Commissioners have communicated that they will address our concerns in September 2018 after the completion of the NHS111 procurement process in the North East of England.” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Implementing the new ambulance response standards requires £10.4 million recurrent investment; the £3.9 million shortfall prevents full delivery pending funding discussions.
Verbatim wording from the response “Delivery of the new ambulance response standards is dependent on receipt of a recurrent annual cost of investment of £10.4 million, identified from the ORH report, of which:” Source location 2018-0059-North-East-Ambulance-Service-NHS-Trust
Open published response
26 Jan 2018 Andrew Stephen Finlay · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to ensure timely dispatch and arrival of ambulance crews in response to 999 calls View source Unfilled paramedic vacancies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Stephen Finlay · 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
Andrew Stephen Finlay, aged 54, collapsed at home on 13 December 2016 and died there the following day. Although expert evidence indicated that the delay in dispatching and arriving with an ambulance did not affect the outcome, concerns remained about delays in emergency ambulance responses, including ongoing paramedic vacancies.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely dispatch and arrival of ambulance crews in response to 999 calls
Wider context from the report “However, it is the 2nd such Report in recent months that I have written about the timely despatch and arrival of an ambulance crew in response to a 999 call.
I heard evidence about the reviews of procedures undertaken since Andrew’s death, but I still have concerns.
Although the plans for the recruitment and retention of personnel and the purchase of additional vehicles were encouraging to hear evidence about, I was told there were still 32 paramedic vacancies to be filled a year after Andrew’s death.
For Andrew the delay made no difference, but for someone else it might. Accordingly it is my duty to write this Report to you, particularly as it may add impetus to the improvement plan.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unfilled paramedic vacancies
Wider context from the report “However, it is the 2nd such Report in recent months that I have written about the timely despatch and arrival of an ambulance crew in response to a 999 call.
I heard evidence about the reviews of procedures undertaken since Andrew’s death, but I still have concerns.
Although the plans for the recruitment and retention of personnel and the purchase of additional vehicles were encouraging to hear evidence about, I was told there were still 32 paramedic vacancies to be filled a year after Andrew’s death .
For Andrew the delay made no difference, but for someone else it might. Accordingly it is my duty to write this Report to you, particularly as it may add impetus to the improvement plan.
” Open source report
×
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 Work with acute hospitals to reduce handover delays.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
Open published response
×
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 recruitment campaign to reduce paramedic vacancies and reach the workforce-plan establishment.
Verbatim wording from the response “Through the completion of a robust recruitment campaign, the Trust reduced the 20% vacancy rate and reached full establishment against its 16/17 workforce plan in March 2017.” Source location Andrew-finlay-Response
Open published response
×
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 Discuss additional resource requirements with the Lead Commissioner and submit a formal contract variation.
Verbatim wording from the response “As a result, the Trust and Lead Commissioner jointly commissioned a demand and capacity review which was published in January 2018. The review identified further resource, 79 paramedics and associated equipment, vehicles and support staff, is still required over and above the previously agreed 42 paramedics in order to meet the new Ambulance Response Programme targets. The Trust is therefore now in discussions with their Lead Commissioner on how to progress this and a formal contract variation has been submitted.” Source location Andrew-finlay-Response
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 Reduce sickness absence and staff abstraction.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
Open published response
×
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 Operate three double-crewed ambulances on daily afternoon and evening shifts in locations aligned with demand.
Verbatim wording from the response “There are 3 new double crewed ambulances that have been running since November 2017 covering a 14:00-02:00 shift daily. This is where our demand profile has increased with our peak demand falling into early afternoon and evening. These vehicles are spread geographically across our area based on our demand profile” Source location Andrew-finlay-Response
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 Secure funding for resources to recruit 84 additional staff, including 42 paramedics and 42 clinical care assistants.
Verbatim wording from the response “However, as a result of the CQC published report, following discussions with the Trust Commissioners, the Trust were successful in securing additional funding for the contract year 2017/18 which provided resources to recruit 84 extra staff, this being 42 paramedics and 42 clinical care assistants, along with associated vehicles and equipment. This funding however was not planned for release until October 2017 and February 2018. Our current vacancy rate which reflects this new establishment mentioned above is now at 7%. Our attrition rate has also reduced to 6.98% therefore slowing the number of staff leaving the Trust.” Source location Andrew-finlay-Response
Open published response
×
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 Tackle hospital handover-to-clear delays, which have already been reduced by nearly 20%.
Verbatim wording from the response “Notwithstanding the above, we accept that we can contribute to improved performance by addressing inefficiencies and have already started to tackle handover to clear time at hospitals, reducing sickness absence, abstraction and working with acute hospitals to reduce handover delays. A good example is the progress we have made in reducing handover to clear delays which have already reduced by nearly 20%. We are hampered in making further progress without having the management capacity to address the issue on site across the Emergency Departments. This is a concrete example of where we need additional resources to help us fully realise the efficiencies.” Source location Andrew-finlay-Response
Open published response
×
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 Run regular paramedic training courses across the financial year and schedule additional courses to meet pipeline demand.
Verbatim wording from the response “In order to close this vacancy rate we have regular paramedic training courses planned across the financial year, with courses commencing in April, June, September, October 2018 and February 2019. The number of courses is regularly reviewed and additional courses scheduled to meet the demands of the paramedic pipeline.” Source location Andrew-finlay-Response
Open published response
×
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 Conduct regular paramedic assessment dates.
Verbatim wording from the response “We have 41 graduates from Teesside University who will be available to commence practice from September 2018. In addition the Trust have regular paramedic assessment dates planned and are looking at a further proactive advertising campaign to include social media adverts in order to attract paramedics to the region.” Source location Andrew-finlay-Response
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 Commission and complete a demand and capacity review for the Ambulance Response Programme workforce requirements.
Verbatim wording from the response “It was acknowledged however by our commissioners, that further demand and capacity profiling would need to be carried out as a result of the introduction of the new Ambulance Response Programme (ARP) in October 2017 and that the 84 extra staff would likely not meet the overall workforce gap.” Source location Andrew-finlay-Response
Open published response
10 Nov 2017 Darren James Powney · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 7 Failure of emergency staff to be aware of the applicable protocol View source Process confusion causing delays in emergency response View source Lack of a firm, clear training programme for the new protocol View source Failure to ensure sufficiently rapid escalation to senior managers View source Failure of dynamic risk assessments to facilitate ambulance crews requesting further information or clarification View source Lack of a bespoke policy for frequent callers View source Violence or threats of violence against emergency responders View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren James Powney · 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
Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency staff to be aware of the applicable protocol
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016 . It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Process confusion causing delays in emergency response
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay , made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a firm, clear training programme for the new protocol
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme . In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficiently rapid escalation to senior managers
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid .
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of dynamic risk assessments to facilitate ambulance crews requesting further information or clarification
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification , as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a bespoke policy for frequent callers
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016 . I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Violence or threats of violence against emergency responders
Wider context from the report “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it . Darren’s death has highlighted the process our emergency responders now have to go through.
I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid.
Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention.
For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest.
” Open source report
×
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 and update Special Patient Notes and Frequent Caller standard operating procedures through the appointed specialist team.
Verbatim wording from the response “As part of the organisational restructure we have reviewed how we manage Special Patient Notes and have appointed a team focused on this and ‘Frequent Callers’. We are currently reviewing our existing Standard Operating Procedures, which will be completed by March 2018.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Audit frontline staff knowledge and awareness of the Joint Operating Procedure.
Verbatim wording from the response “• Our staff's knowledge and awareness of the JOP is to be audited;” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Provide operational staff with statutory and mandatory dynamic-risk-assessment, conflict-resolution and breakaway training.
Verbatim wording from the response “Operational crews receive conflict resolution training, breakaway training and dynamic risk assessment training as part of Statutory and Mandatory training, this also includes use of the joint decision making model. The Trusts data currently shows that 88% of operational staff have received statutory and mandatory training.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Disseminate Joint Operating Procedure and dynamic-risk-assessment guidance through staff briefings, memoranda, meetings, face-to-face sessions, induction and operational assurance activities.
Verbatim wording from the response “We have undertaken a range of measures to ensure staff understand the JOP and how it applies to them in practice as follows:” Source location 2017-0346-Response-by-North-East-Ambulance-Service-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 Escalate unsafe property-access decisions to senior operational managers for review and direct crew support.
Verbatim wording from the response “In order to address this we have ensured that when a crew does not feel safe to proceed and access a property, without police support, based on the ‘flag’ this is then escalated to the Clinical Operation Manager or the Assistant Services Manager on duty so they may review all information available and speak directly to the crew on scene.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Test frequent-caller flagging and establish a multidisciplinary process to review cases and refer appropriate patients for primary-care or multidisciplinary-team involvement.
Verbatim wording from the response “We have tested our flagging system to provide assurance that it is highlighting ‘frequent callers’ and are establishing a wider internal multi-disciplinary group, to include patient safety and safeguarding to review cases and refer on to primary care for case review / Multi-disciplinary Team involvement.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 install vehicle dashboard stickers prompting dynamic risk assessment before requesting police support.
Verbatim wording from the response “Undertaking a dynamic risk assessment is central to the work we do in delivering safe patient care as an Ambulance Trust. In order to reinforce to front line crews key areas to consider when informed that there is a flag relating to possible violence and aggression, a sticker has been developed to be placed in the front of the vehicle with prompts to consider prior to requesting police support. Following agreement with the relevant departments this is currently being produced and will be in all vehicles by the end of March 2018.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
×
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 Implement Joint Operating Procedure version 14, including the cross-service escalation process for differing risk assessments.
Verbatim wording from the response “As discussed at the inquest and as a result of Darren's death, the JOP was reviewed by Alan Gallagher, the Trust's Head of Risk, and Chief Superintendent Sav Patsalos, of the Northumbria Police as it was identified that clarification was required regarding who should attend patients when the risk assessments of the two services differ. This has resulted in the creation of an escalation process which was incorporated into the JOP. This enables a review of all information available, oversight of the situation and prompt action. Any cases where this situation has occurred will be reported via the Trust incident reporting system and will be brought to the attention of the Strategic Head of Operations.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-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 Trial body-worn cameras for operational staff and review their impact on violence and aggression.
Verbatim wording from the response “We are committed to keep our staff safe, wherever possible and we are trialling ‘Body Worn’ cameras. These are devices which will be worn by our operational staff members and the trial is to commence in early 2018. The Trust will look at the feedback and review whether the use of the cameras has had an impact on reducing violence and aggression against staff.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-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 Formal collective launch of the Joint Operating Procedure was considered ceremonial because stakeholders had already agreed and used it in daily routines.
Verbatim wording from the response “The Trust can confirm that the JOP is currently being used by the stakeholders and will continue to evolve as part of the Trust's collaborative work with Police colleagues. Whilst the JOP has not yet been formally collectively launched, plans are being made for the various Executive teams to meet and jointly sign the current version. The dates suggested for this meeting commence on the 6th February 2018 with partners being asked to provide availability. The plans also include a joint media launch so the work can be publically shared to show the on-going collaboration between the emergency services. The Trust would however like to assure you that this is more of a ceremonial matter linked with promoting our collaboration. As stated above all three Police Forces and the Trust have agreed the JOP and use it in our daily routines.” Source location 2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
Open published response
2 Dec 2016 Joshua Harry Smith · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 7 Searches being stood down without confirming reported safety information View source Delay in deploying the Hazardous Area Response Team to a hazardous-area incident View source Failure to recognise location information from 999 calls View source Unclear multi-agency command control and co-ordination View source Failure to identify location from mobile 999 calls View source Failure to immediately alert police and other emergency services from 999 call information View source Failure to provide police control with essential incident information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua Harry Smith · 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
Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Searches being stood down without confirming reported safety information
Wider context from the report “The search for Joshua was briefly stood down after a North East Ambulance call to Joshua’s father indicated that Joshua was at home in his bedroom, without waiting for ████████ to check and confirm whether Joshua was in fact in his bedroom.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in deploying the Hazardous Area Response Team to a hazardous-area incident
Wider context from the report “Joshua had explained in his 999 call that he was below cliffs having fallen, was injured and that an ambulance would not be able to reach him. The Hazardous Area Response Team of North East Ambulance was not deployed to the incident until approximately 3 a.m. arriving at the scene under an hour later and were 1.5 miles away from the incident at the time Joshua was swept out to sea by action of the waves.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise location information from 999 calls
Wider context from the report “The search for Joshua continued at Berwick Holiday Park (on the north side of the River Tweed and the town of Berwick-upon-Tweed) as a result of his location at Spittal Beach not being recognised from his 999 call .
After Joshua’s phone call was ‘listened back’ it was observed that he had described his location as Spittal, at the bottom of a cliff, near Spittal beach.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear multi-agency command control and co-ordination
Wider context from the report “The circumstances of the death showed that although there were examples of good co-operation and effort among the emergency services, overall command, control and co-ordination were unclear and JESIP was not followed.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify location from mobile 999 calls
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately alert police and other emergency services from 999 call information
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police control with essential incident information
Wider context from the report “Two Police Officers on Berwick Town Centre duties (which is north of the River Tweed) were asked in the street by paramedics for assistance in locating Joshua, and while paramedics went to look for Joshua on the north side of Berwick near the Holiday Park and cliffs, the police officers travelled to Spittal looking for Joshua although they had no name or further details at that time . A brief search of Spittal beach near to the cliffs by Police Officers was unsuccessful, before they returned to Town Centre duties. A report to Police Control was not made at that time.
” 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 Repeat NDM and JESIP training for NEAS operational staff during 2017/18.
Verbatim wording from the response “With the above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways licence requirements and maintain focus on the clinical complaint. However, in order to enhance the skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers that would alert them to the need for other emergency services, as a result of joint work with Police colleagues, a specific THRIVE training program for NEAS has been devised with commencement of delivery in March 2017. This further training will ensure that there is, so far as possible, a consistency of response between Control Room staff across agencies. Furthermore, NEAS operational staff have received training in NDM and Joint Emergency Services Interoperability Programme (JESIP) principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Consider sourcing Mountain Rescue expertise and using SARLOC to improve location identification in relevant incidents.
Verbatim wording from the response “Your report identifies the fact that Joshua’s location could not be clearly identified using his mobile phone. As you are aware, the topography of the area (on or near cliffs) made triangulation difficult. Northumberland National Park Mountain Rescue have advised other agencies of a further software tool available to them, SARLOC, which enables a text message to be sent to a missing person’s phone. If the phone is a smartphone, the missing person is then able to click on the message and, using the internet, the smartphone provides Mountain Rescue with the location. Although this system cannot be independently utilised by other agencies, Mountain Rescue teams are able to distribute a notification of the casualty’s whereabouts to all partner agencies upon notification of an incident to them.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Provide Tactical Advisors to support faster tactical responses and improve inter-agency communication.
Verbatim wording from the response “As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised in your Report), and a decision regarding the appropriation of this response is made more quickly and (2) communication between agencies is improved. This very point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated “Control action following 999 calls to water incidents” procedure in use at NEAS. The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Finalise, approve and use the revised procedure for responding to 999 calls concerning water-based incidents.
Verbatim wording from the response “As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised in your Report), and a decision regarding the appropriation of this response is made more quickly and (2) communication between agencies is improved. This very point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated “Control action following 999 calls to water incidents” procedure in use at NEAS. The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Deliver THRIVE training to NEAS call handlers to improve identification of triggers requiring other emergency services.
Verbatim wording from the response “With the above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways licence requirements and maintain focus on the clinical complaint. However, in order to enhance the skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers that would alert them to the need for other emergency services, as a result of joint work with Police colleagues, a specific THRIVE training program for NEAS has been devised with commencement of delivery in March 2017. This further training will ensure that there is, so far as possible, a consistency of response between Control Room staff across agencies. Furthermore, NEAS operational staff have received training in NDM and Joint Emergency Services Interoperability Programme (JESIP) principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Conduct further HART operative training for incidents in or near water.
Verbatim wording from the response “As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised in your Report), and a decision regarding the appropriation of this response is made more quickly and (2) communication between agencies is improved. This very point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated “Control action following 999 calls to water incidents” procedure in use at NEAS. The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
×
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 Provide NDM and JESIP training to NEAS operational staff.
Verbatim wording from the response “With the above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways licence requirements and maintain focus on the clinical complaint. However, in order to enhance the skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers that would alert them to the need for other emergency services, as a result of joint work with Police colleagues, a specific THRIVE training program for NEAS has been devised with commencement of delivery in March 2017. This further training will ensure that there is, so far as possible, a consistency of response between Control Room staff across agencies. Furthermore, NEAS operational staff have received training in NDM and Joint Emergency Services Interoperability Programme (JESIP) principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period.” Source location 2016-0599-Response-by-Northumbria-Police
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 NEAS cannot remove closed questioning because Call Handlers must comply with NHS Pathways licence requirements and maintain clinical focus.
Verbatim wording from the response “A number of questions asked by the Call Handler were of the “closed” type, which limited the opportunity for Joshua to be more specific about his location. The nature of the questions posed by the Call Handler may be explained by the fact the NHS Pathways telephone triage system in use by the North East Ambulance Service requires Call Handlers to ask closed questions in order to identify the nature of the medical complaint and provide the most accurate ambulance response. Failure to follow NHS Pathways may lead to increased clinical risk and, ultimately, potentially unsafe calls.” Source location 2016-0599-Response-by-Northumbria-Police
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 HM Coastguard is responsible for considering improved Airwave access to facilitate inter-agency communication.
Verbatim wording from the response “The multi-agency meeting also identified that whilst the new Coastguard helicopter has Airwave capability (the standard communication system utilised by land based agencies), HM Coastguard currently only have limited access to the Airwave system. HM Coastguard are currently giving consideration to improving their Airwave capability, in order to facilitate communication between agencies.” Source location 2016-0599-Response-by-Northumbria-Police
Open published response
26 Aug 2016 Kyle William Lowes · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 2 Lack of assured paramedic crew availability during meal breaks after 10.00 p.m. in Berwick-upon-Tweed View source Insufficient local ambulance crew availability when the single Berwick crew is deployed out of area after 10.00 p.m. 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
Kyle William Lowes · 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
Kyle William Lowes, aged 16, died after his motor scooter collided with a car in Berwick-upon-Tweed on 30 January 2015. Emergency response was delayed because the nearby Berwick ambulance crew was on a meal break, requiring a paramedic to travel from Wooler; the report raised concerns about delayed responses to life-threatening incidents in Berwick-upon-Tweed when only one crew is available or is outside the area.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assured paramedic crew availability during meal breaks after 10.00 p.m. in Berwick-upon-Tweed
Wider context from the report “The new Northumbria Specialist Emergency Care Hospital now make better provision for the County of Northumberland as a whole, but extends still further the long journey times for emergency care from Berwick-upon-Tweed, a sizeable border town, with a population which trebles throughout the tourist season because of its location as a holiday destination. By having only one paramedic crew after 10.00 p.m., if that crew is on a meal break , or as they regularly need to do, attend duties in another part of the County, risk is created to the population of Berwick-upon-Tweed by significant delays in attending life threatening incidents after 10.00 p.m., as there was in Kyle’s case.
I was informed at the Inquest that NEAS are introducing a scheme whereby paramedic crews will be asked at the start of each shift whether they are willing to be contacted for emergency calls during their meal breaks, which might go some way towards helping to resolve the concerns but does not provide any certainty while resting only on the goodwill and agreement of ambulance personnel . This proposal for response to emergency calls during meal breaks would also not address the risk of delayed response times when the single Berwick ambulance crew after 10.00 p.m. is called upon for duties out of the area.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient local ambulance crew availability when the single Berwick crew is deployed out of area after 10.00 p.m.
Wider context from the report “The new Northumbria Specialist Emergency Care Hospital now make better provision for the County of Northumberland as a whole, but extends still further the long journey times for emergency care from Berwick-upon-Tweed, a sizeable border town, with a population which trebles throughout the tourist season because of its location as a holiday destination. By having only one paramedic crew after 10.00 p.m., if that crew is on a meal break, or as they regularly need to do, attend duties in another part of the County , risk is created to the population of Berwick-upon-Tweed by significant delays in attending life threatening incidents after 10.00 p.m., as there was in Kyle’s case.
I was informed at the Inquest that NEAS are introducing a scheme whereby paramedic crews will be asked at the start of each shift whether they are willing to be contacted for emergency calls during their meal breaks, which might go some way towards helping to resolve the concerns but does not provide any certainty while resting only on the goodwill and agreement of ambulance personnel. This proposal for response to emergency calls during meal breaks would also not address the risk of delayed response times when the single Berwick ambulance crew after 10.00 p.m. is called upon for duties out of the area .
” Open source report
23 Mar 2016 Mandeep SINGH · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 2 Ambulance shortages amid severe demand View source Road closures and diversions affecting ambulance crew access View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mandeep SINGH · 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
Mandeep SINGH consumed high levels of alcohol and was found unconscious at home at approximately midnight after his wife found him lying on the floor. Although the ambulance call was assessed as R1 with a target response time of 8 minutes, the ambulance arrived after 27 minutes, and Mr Singh died in the ambulance. The investigation identified severe demand and staff shortages, as well as road closures and diversions, as factors in the delay.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambulance shortages amid severe demand
Wider context from the report “A root cause analysis comprehensive and independent investigation report undertaken by the North East Ambulance Service discloses that the reasons for the delay of the ambulance arrival include severe demand and shortages in the division . Road closures and diversions did not assist the crews.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Road closures and diversions affecting ambulance crew access
Wider context from the report “A root cause analysis comprehensive and independent investigation report undertaken by the North East Ambulance Service discloses that the reasons for the delay of the ambulance arrival include severe demand and shortages in the division. Road closures and diversions did not assist the crews .
” 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 Deploy Hospital Ambulance Liaison Officers and Emergency Care Clinical Managers to improve hospital handover and ambulance turnaround.
Verbatim wording from the response “The Trust once again deployed Hospital Ambulance Liaison Officers (HALOs) across the region during the winter period, in order to assist both hospitals and ambulance crews during times of pressure. The HALOs ceased their role in March 2016. This responsibility has now been taken up by the ECCMs who undertake this role throughout the rest of the year.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Run a six-month trial dispatching Emergency Medical Responders alongside ambulances for life-threatening community emergencies.
Verbatim wording from the response “In January 2016, the Trust commenced a new six-month trial scheme with the four Fire and Rescue Services based in the region. This includes Cleveland Fire Brigade, County Durham and Darlington Fire and Rescue Service, Northumberland Fire and Rescue Service and Tyne and Wear Fire and Rescue Service.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Review the appropriateness of Red calls to reduce avoidable demand.
Verbatim wording from the response “The Trust has also carried out demand reduction work looking at how to reduce the number of red calls made by looking at the appropriateness of those red calls.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Deploy Emergency Care Clinical Managers to spend half their time on frontline work and cover operational shifts.
Verbatim wording from the response “The Trust has also recruited a total of 56 Emergency Care Clinical Managers (ECCMs) who have been recruited from the current team leader pool. ECCMs manage the Trust's ambulance stations and ordinarily spend 90% of their time undertaking management/supervisory/governance work, with the remaining 10% on the front line. However, in order to help ease frontline pressures in the current climate, the ECCMs will spend 50% of their time working on the front line and will be able to cover a number of shifts.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 an arrangement for volunteers to respond to Red 1 calls during meal breaks.
Verbatim wording from the response “The question as to whether staff should be available to respond to calls during their statutory meal break has been debated extensively by the Association of Ambulance Chief Executives and with the Secretary of State for Health. We have held detailed discussions with other ambulance services about this issue also. The Trust have now proposed to the paramedic Unions that crews should be asked whether they will agree to cease their meal break in order to attend life threatening Red 1 (8 minute emergency response) calls. This proposal was initially rejected by the Unions. However, we have continued to seek the Unions' engagement on this issue and both Unison and GMB have since both agreed in principle for their members to be asked to volunteer to respond to R1 calls while they are on their break.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Implement winter care projects and engage alternative care pathways to manage suitable patients outside hospital.
Verbatim wording from the response “Furthermore, the Trust has been working closely with the local Clinical Commissioning Groups to sustain and improve the provision of patient care over the winter periods through specific winter projects. A winter care plan was in place to help alleviate the additional seasonal pressures. The Trust has also undertaken a review of its agency and partnership arrangements in order to determine if current arrangements can be improved. These measures are aimed at maximising patient care within the home environment, where appropriate, in order to avoid unnecessary Accident and Emergency Department attendances. This is designed to increase Trust emergency ambulance resource availability. The Trust also continues to engage with other providers/pathways in order to manage patients outside of hospital, where appropriate.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Change the Patient Transport Service meal-break policy to permit breaks away from base stations and improve resource availability.
Verbatim wording from the response “In addition, there was to be a change to the meal break policy across the Trust PTS team in order to enable staff to be able to take their meal breaks at locations away from their base stations and at other sites. Pursuant to the previous meal break policy, staff returned to their own base stations in order to have their compulsory meal break and were effectively unable to respond to any incoming calls during this period. The aim was therefore to reduce travelling time going to/from base stations and to improve resource allocation and utilisation of staff time by reducing travelling. Such changes were also intended to reduce vehicle usage, with less fuel and vehicle maintenance being required, therefore allowing the Trust to keep more vehicles on the road to attend emergency calls.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Work with GPs and other health colleagues to reduce requests for ambulance transfers.
Verbatim wording from the response “The Trust has worked with colleagues in relation to demand reduction. The Trust has worked with health colleagues for example GP’s, to ascertain whether requests for ambulance transfers can be reduced.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Continue using Advanced Paramedic Practitioners to assess and treat suitable patients at home, reducing unnecessary emergency transfers.
Verbatim wording from the response “Finally, the Trust are also continuing to utilise Advanced Paramedic Practitioners (APPs). These clinicians have proven advanced patient assessment skills of the same level as Emergency Care Practitioners and are able to assess, treat and in most cases, ensure that the patient is safely treated at home, where appropriate. As a result, suitable patients are assessed and treated by APPs in their own home if this is more appropriate than a transfer to hospital. This forms part of the Trust's focus on improving patient care and experience, as well as to reduce the demand on front line emergency crews by recognising the importance of ensuring that only those patients who are in need of a hospital admission in an emergency situation receive an emergency ambulance disposition.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Review agency and partnership arrangements to identify improvements.
Verbatim wording from the response “Furthermore, the Trust has been working closely with the local Clinical Commissioning Groups to sustain and improve the provision of patient care over the winter periods through specific winter projects. A winter care plan was in place to help alleviate the additional seasonal pressures. The Trust has also undertaken a review of its agency and partnership arrangements in order to determine if current arrangements can be improved. These measures are aimed at maximising patient care within the home environment, where appropriate, in order to avoid unnecessary Accident and Emergency Department attendances. This is designed to increase Trust emergency ambulance resource availability. The Trust also continues to engage with other providers/pathways in order to manage patients outside of hospital, where appropriate.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Work with police to reduce ambulance requests made by police.
Verbatim wording from the response “The Trust has also worked with the police to see if any reduction in ambulances requested by the police can be effected.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Implement an overtime policy increasing paramedic availability across shifts.
Verbatim wording from the response “On a separate note, the Trust has been planning for some time to implement a new overtime policy which would see an increased number of paramedic resources being available across all shifts. This has taken a while to implement as a consequence of extensive negotiations with the Unions however the Trust anticipate such a policy being introduced very shortly.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Arrange for Sunderland University to train paramedics on demand rather than only according to the academic year.
Verbatim wording from the response “An arrangement has also been negotiated with Sunderland University whereby they will train paramedics as and when requested by the Trust and not just in line with the academic year in order to help match our demand.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Provide updated training for former staff joining the paramedic bank.
Verbatim wording from the response “The Trust has also implemented a paramedic bank for recent leavers, whereby qualified paramedics who leave the Trust's employment, are asked whether they are interested in joining the Trust's paramedic bank. This is designed to increase the number of qualified paramedics available to fill vacant shifts. The Trust proceeded to complete recruitment checks on these individuals and will provide updated training for ex-members of staff who join the paramedic bank. It was initially anticipated that these individuals would be available to undertake frontline clinical duties from around May 2015. Given the recruitment pressures which the Trust has faced, this was pushed back slightly, however the paramedic bank has been in place since around October/November 2015, therefore allowing cover for the winter pressure period.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Use framework third-party crews, vehicles and equipment to cover vacant shifts and resource shortfalls.
Verbatim wording from the response “Third party agencies on the Trust's local framework continue to be utilised on a daily basis in order to provide support and to assist with responding to G2 (30 minute) and low priority emergency and GP urgent calls, which are within their capability. Third party providers on the framework are trained to an equivalent level as a Trust Ambulance Technician or a Trust PTS Assistant. The Trust is still currently seeking qualified paramedics from third party providers as a further short term solution to increasing higher skilled operational roles whilst recruitment continues pursuant to the above mentioned Workforce Plan. Using the Trust's local third party framework, an agreement has been reached where our third party partners can be drawn upon to cover short falls in emergency and urgent care resources, where necessary.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Continue workforce recruitment strategies beyond ordinary workforce planning to increase emergency-care resources.
Verbatim wording from the response “In light of the above issues, all ambulance services across the country, including the Trust, are pursuing various workforce recruitment strategies in an attempt to increase their emergency care resource base. Over the last 12 months, the Trust has improved its paramedic resource base and attrition rates have improved, whereby there are now more paramedics commencing roles at the Trust than the number of staff leaving employment. At this stage, the Trust has a skill vacancy of around 20% which has reduced from 25%. The Trust's attrition rate has therefore improved in comparison to other ambulance services across the country. However, there still remains a shortfall of people entering the paramedic profession nationally. As such, the Trust will continue with its workforce recruitment strategies which go beyond ordinary workforce planning.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Recruit internationally qualified paramedics, including processing recruits from Poland for frontline roles.
Verbatim wording from the response “Moreover, the Trust had also placed an advert for qualified paramedics in the periodical "Ambulance Life" which has an international reach and has been pursuing other international recruitment campaigns. This has resulted in the recruitment of 19 paramedics from Poland, with 4 individuals ready to commence front-line clinical roles and the remaining 15 currently being processed.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Recruit an additional 40 student paramedics during 2016–2017.
Verbatim wording from the response “At this stage, the Trust has recruited 104 student paramedics and 204 emergency care assistants since January 2014. In addition the Trust has planned to recruit an additional 40 student paramedics during 2016/2017. The Trust has also recruited 31.5 qualified paramedics and will continue to recruit in this role with a healthy pipeline. The emergency care assistants and technicians will support paramedics in attending emergency calls, including driving the ambulance and assisting with medical intervention, having been trained in basic life support.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Integrate Patient Transport Service staff into the workforce system and allocate work matching their skills.
Verbatim wording from the response “In addition, the Trust has been looking to increase the number of PTS (Patient Transport Service) staff. A PTS member of staff transports patients to and from planned appointments at a range of healthcare providers. Our PTS staff are now fully integrated into the Trust's workforce system and are allocated jobs appropriate to their skill base. This should help free up the Trust's more experienced and qualified paramedics to deal with the most urgent emergency calls.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Operate the Emergency Care Workforce Plan and Task and Finish Group to increase emergency workforce numbers and address paramedic attrition.
Verbatim wording from the response “In order to seek to address this shortfall, the Trust has been following an Emergency Care Workforce Plan. This Workforce Plan has always existed however, given the increase in attrition of staff, a Task and Finish Group was established in October 2014, in order to ensure that the Trust is employing as many strategies as possible to increase emergency workforce numbers. This includes a two-year programme designed to increase the number of paramedics employed by the Trust and involves various initiatives which are aimed at tackling the problem of paramedic attrition. We will explain in greater detail below the specific steps which the Trust is taking pursuant to the Workforce Plan to address resource and recruitment issues. It was previously hoped that the process to address the current shortfall in paramedics would be fully addressed by September 2016.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Operate the interim Operational Recovery Action Plan using short-term measures and third-party providers to increase daily operational resources.
Verbatim wording from the response “The Trust have also implemented an interim Operational Recovery Action Plan, which focuses on short term solutions to deal with operational resource availability and is expected to increase the Trust's resources on a day to day basis by utilising third party providers to fill current vacancies. A number of initiatives have also been implemented to improve response times to low priority calls (i.e. calls which are not categorised as a red '8 minute' emergency response).” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Use Ambulance Resource Assistants to restock equipment and position vehicles so crews return to incidents sooner.
Verbatim wording from the response “Similarly, the Trust has sought to make use of dedicated Ambulance Resource Assistants (ARAs) over the recent winter periods, who play a key role in supporting the utilisation of our front line emergency and PTS crews by ensuring equipment and consumables are restocked at hospitals and operational stations, thereby reducing the need for crews to travel back to core sites to restock, losing valuable operational time which could be spent responding to incidents. The ARAs also ensure that vehicles are transported to the appropriate locations for the commencement of shifts, thereby maximising the utilisation time amongst crews responding to incidents.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Operate a paramedic bank for recent leavers to provide additional qualified cover for vacant shifts.
Verbatim wording from the response “The Trust has also implemented a paramedic bank for recent leavers, whereby qualified paramedics who leave the Trust's employment, are asked whether they are interested in joining the Trust's paramedic bank. This is designed to increase the number of qualified paramedics available to fill vacant shifts. The Trust proceeded to complete recruitment checks on these individuals and will provide updated training for ex-members of staff who join the paramedic bank. It was initially anticipated that these individuals would be available to undertake frontline clinical duties from around May 2015. Given the recruitment pressures which the Trust has faced, this was pushed back slightly, however the paramedic bank has been in place since around October/November 2015, therefore allowing cover for the winter pressure period.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Transfer advanced technicians into frontline operational roles to relieve lead-clinician pressures.
Verbatim wording from the response “At the same time, the Trust has been transferring advanced technicians to frontline operational roles in order to reduce frontline pressures for lead clinicians. 20 members of staff have so far agreed to this. Advanced technicians, like paramedics, are trained to deal with life threatening illnesses and injuries. They are therefore very experienced members of staff. However, paramedics are also trained to undertake invasive procedures which may need to be performed during the most serious medical emergencies, including intubation (where a tube is inserted into the windpipe to help a patient breathe) and cannulation (where a thin tube is inserted into a vein in order to introduce fluid and drugs as quickly as possible).” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Recruit student paramedics, emergency care assistants and qualified paramedics to increase emergency response capacity.
Verbatim wording from the response “The Trust has been actively working to recruit more paramedics into the service in order to increase the resources it has available to respond to the higher volume of emergency calls which it is required to deal with in the present climate. The Trust has always had a workforce plan in place however new strategies have since been introduced after the Trust discovered in/around mid-2014 that more paramedics were leaving their employment than the numbers being recruited to fill vacancies.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Educate the public about appropriate ambulance-service use through extensive advertising and vehicle signage.
Verbatim wording from the response “The Trust is limited in ways in which it can control the calls made to it and the demand on its services. However, the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Increase recruitment, human-resources and training staffing capacity to fill frontline vacancies more quickly.
Verbatim wording from the response “In addition to those measures set out above, in the long term, the Trust has been looking to increase its own recruitment capacity, by employing more staff in recruitment, human resources and training roles. This will enable new staff to be recruited and trained in a timely manner in order to fill frontline vacancies. This remains the case.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Increase the in-house graduate paramedic training programme from 24 to 48 places with two annual intakes.
Verbatim wording from the response “As noted above, one major issue faced by Ambulance Trusts nationally with respect to recruitment is the fact that all would-be paramedics have to undertake a 2 year training course at University, which effectively means that the Trust has to recruit 2 years in advance of employment commencement. As such, and in order to attempt to tackle the resource shortfall, the Trust has increased the number of places on its 2 year in-house graduate training programme from the usual 24 places to 48 places, with a two-stage intake in February and April. This results in the Trust having a year-end forecast number of student paramedics of approximately 100. The Trust have also visited universities in an attempt to recruit paramedics who are pursuing their studies but are not yet licensed to a particular ambulance service upon qualification.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Introduce tri-responders working across police, fire and ambulance services.
Verbatim wording from the response “Finally the Trust has worked in partnership with Durham Constabulary and County Durham and Darlington Fire and Rescue Service to introduce the region’s first tri-responders working for police, fire and ambulance. The Community First Responders work for Durham Constabulary as PCSOs, County Durham and Darlington Fire and Rescue Service as retained firefighters and as first responders for the NEAS.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
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 Control over calls and demand is limited, although demand-reduction initiatives are undertaken.
Verbatim wording from the response “The Trust is limited in ways in which it can control the calls made to it and the demand on its services. However, the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.” Source location 2016-0116-Response-by-North-East-Ambulance-Service
Open published response
21 May 2015 Barbara Patterson · Prevention of Future Deaths report Northumberland (North)
View report summary
Concerns raised 6 Delays in ambulance crew handover at hospitals reducing ambulance availability View source Failure of the Pathways system to prompt CPR advice for patients with agonal breathing View source Failure by call handlers to give timely CPR advice View source Delays in ambulance arrival beyond the target response time View source Failure by ambulance dispatchers to dispatch the closest available ambulance View source Shortage of paramedics 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
Barbara Patterson · 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
Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.
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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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance crew handover at hospitals reducing ambulance availability
Wider context from the report “6. During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Pathways system to prompt CPR advice for patients with agonal breathing
Wider context from the report “2. During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing . This fails to recognise the need for CPR in cases of Agonal (heavy/noisy breathing which is insufficient to sustain life) . This fault was pointed out to Pathways by the Clinical Section Manager for North East Ambulance Service NHS Foundation Trust, prior to the latest update being installed in early 2014 (Update 9). Pathways refused to amend the system. That fault remains in place to date .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by call handlers to give timely CPR advice
Wider context from the report “1. The failure by the Call Handler to give timely advice in respect of CPR .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance arrival beyond the target response time
Wider context from the report “4. The target time for the arrival of the ambulance was 8 minutes, this was breached . The ambulance did not arrive for 15 minutes .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by ambulance dispatchers to dispatch the closest available ambulance
Wider context from the report “3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased’s location
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of paramedics
Wider context from the report “5. During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East .
” Open source report
Concerns raised 10 Insufficiently thorough and incisive investigation of safety incidents View source Failure to ensure all 111 service providers understand the limitations of the BT service for disclosing data sensitive information View source Delays in referring cases and dispatching ambulances after failure to obtain caller location information View source Failure to ensure that life-saving procedural information reaches all staff involved in call handling View source Absence of a clear and robust policy and practice for addressing caller-location problems View source Delays in providing substantive safety advice to control room staff after potential systemic failures are identified View source Failure to ensure 111 and ambulance dispatch staff know and are trained in procedures for locating seriously ill patients with incomplete whereabouts information View source Absence of specific training on caller-location and dispatch procedures View source Failure to provide BT with complete information when requesting release of a caller's address View source Failure of ambulance service protocols to address caller-location and dispatch problems View source See 7 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
Gary William Million · 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
Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.
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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently thorough and incisive investigation of safety incidents
Wider context from the report “4. A detailed investigation that was undertaken by North East Ambulance Trust is upon closer examination, in places lacking depth and incisiveness .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all 111 service providers understand the limitations of the BT service for disclosing data sensitive information
Wider context from the report “2. BT’s evidence was that they have given further advice and information to blue light service providers (namely Fire, Police, Ambulance, Coastguard) but as they do not know of the identity of all 111 providers it is very possible that other 111 providers may not understand the limitations of the BT service for disclosing data sensitive information and therefore, so that this issue can be considered and lessons learnt therefrom the Department of Health ought to consider sharing this information with all other 111 service providers throughout the country to reduce the risk of similar fatalities in the future. A copy of the full Regulation 28 report addressed to North East Ambulance Service Trust is attached.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referring cases and dispatching ambulances after failure to obtain caller location information
Wider context from the report “1. Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that life-saving procedural information reaches all staff involved in call handling
Wider context from the report “7. Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved in the call handling process . No specific training on this important issue has been carried out as at the date hereof and none was planned.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear and robust policy and practice for addressing caller-location problems
Wider context from the report “8. The response to the incident by the Trust appears perfunctory and now, eight months after the death of the deceased, notwithstanding the changes made to practice and procedure by the North East Ambulance Service Trust it is clear that a clear and robust policy and practice to address this issue is not in place .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing substantive safety advice to control room staff after potential systemic failures are identified
Wider context from the report “6. The deceased died in November 2013 and within a day or two of the death being reported, it was clear that the circumstances of the death highlighted serious potential systemic failures and yet, no substantive further advice was given to control room staff until February 2014 .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure 111 and ambulance dispatch staff know and are trained in procedures for locating seriously ill patients with incomplete whereabouts information
Wider context from the report “2. No 111/ambulance dispatch staff knew of or had been trained about the correct procedure to be adopted when trying to locate a potentially seriously ill patient when they had incomplete information as to that persons whereabouts. In short, they did not know how to obtain the callers address . Despite the considerable and well intentioned efforts of a number of people working in the call centre, these individuals failed to locate the deceased’s home address and as a result there was an inordinate delay before the ambulance crew were able to attend the deceased’s property.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of specific training on caller-location and dispatch procedures
Wider context from the report “7. Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved in the call handling process. No specific training on this important issue has been carried out as at the date hereof and none was planned .
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide BT with complete information when requesting release of a caller's address
Wider context from the report “3. When the ambulance service duty manager spoke to BT, that individual did not fully explain the nature and reason for the enquiry with the result that the BT operator was not seized of all relevant information with which he could make a fully reasoned decision as to whether to exercise his discretion or not to release the deceased’s home address to the caller.
” 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 North East Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance service protocols to address caller-location and dispatch problems
Wider context from the report “5. New revised North East Ambulance Service Trust protocols which are undated, and which were produced to the Senior Coroner only on the morning of the Inquest being resumed, do not deal with the problems identified in this case even though they were designed to address them.
” 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