10 Jun 2026 Lesley Katherine HIGGINSON · Prevention of Future Deaths report Cheshire
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Concerns raised 2 Lack of clarity about the policy for declining welfare calls View source Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected 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
Lesley Katherine HIGGINSON · 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
Lesley Katherine HIGGINSON, a medically vulnerable adult aged 72, was found deceased at home on 18 January 2026 after failed remote welfare and medication contacts. A principal concern was uncertainty about the ambulance service policy for declining welfare-check requests, including whether the request in these circumstances was properly rejected and whether responsibility was affected by the police RCRP policy.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the policy for declining welfare calls
Wider context from the report “It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected
Wider context from the report “It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated.
” 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 Meet with Okay Each Day and explain when ambulances will and will not be deployed for concern-for-welfare calls.
Verbatim wording from the response “NWAS have also met with the Okay Each Day service who have been advised as to the circumstances in which an ambulance will and will not be deployed when concern for welfare calls are received. It was recommended by NWAS that Okay Each Day explore whether they could set up a pathway with other agencies to make initial contact with a patient where their exact location cannot be determined or for them to consider their own response team to conduct these enquiries.” Source location Response from North West 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 Introduce and implement Concern for Welfare Response Criteria Guidelines governing receipt, recording, escalation and ambulance responses.
Verbatim wording from the response “This advice was in accordance with the NWAS Concern for Welfare policy, which covers the receipt, recording, escalation and NWAS responses in relation to concern for welfare of a patient. Where such calls are received, the guidelines provide that the patient’s location needs to be known and there needs to be a confirmed medical need.” Source location Response from North West 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 Communicate concern-for-welfare ambulance deployment criteria and limitations to police, acute trusts, mental health organisations and councils through system-partner engagement.
Verbatim wording from the response “The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.” Source location Response from North West 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 NWAS cannot unilaterally provide welfare callouts for people whose needs or locations cannot be established.
Verbatim wording from the response “The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.” Source location Response from North West 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 Other services must independently investigate whether an uncontactable person requires physical or mental healthcare.
Verbatim wording from the response “As an ambulance service, our primary function is to prioritise and respond to the medical needs of our patients whether this is face-to-face or via other methods. A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires either a face-to-face assessment or telephone response. It cannot be assumed that an individual being uncontactable, means that they require medical assistance. Nor do NWAS have the capacity to conduct thorough enquiries, on behalf of other services, to determine whether an individual is experiencing physical or mental health concerns. It is incumbent upon these services to arrange for and execute such inquiries autonomously.” Source location Response from North West 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 Concern for Welfare policy was sufficient because the call lacked a verified location and confirmed physical or mental health need.
Verbatim wording from the response “The NWAS Mental Health and Suicide Prevention Lead has listened to the 999 calls made in respect of Ms Higginson and has confirmed that the 999 call from Okay Each Day at 15:16 hrs was handled appropriately and in line with the concern for welfare policy. It could not be determined that Ms Higginson was at the specified location nor could it be determined that she had a confirmed physical or mental health complaint. It was therefore correct that NWAS did not deploy an ambulance to Ms Higginson based on the information provided at the time of the call.” Source location Response from North West Ambulance Service
Open published response
16 Mar 2026 Jardine Williams · Prevention of Future Deaths report Cumbria
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Concerns raised 2 Failure to return calls from CHOC to NWAS after the third failed contact attempt View source Failure to pass full and accurate information between NWAS and CHOC 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
Jardine Williams · 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
Jardine Williams, a 29-year-old mental health nurse, died on 24 March 2025 after making a 999 call reporting worsening mental health, suicidal thoughts, a plan and an intention to carry it out. The report raised concerns about unclear and confused communication between the North West Ambulance Service and Cumbria Health on Call, including a delay in returning the call after repeated unsuccessful attempts to contact her. The report did not find a causative link between that delay and the outcome, and stated that her intent could not be determined on the balance of probabilities.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to return calls from CHOC to NWAS after the third failed contact attempt
Wider context from the report “As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC.
(1) I found that the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation. I was concerned that full and accurate information was therefore not passing between NWAS and CHOC.
(2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the flow of information between CHOC and NWAS appeared to have confused on this issue.
At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was confirmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours.
I did not find that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours , but that the call was not returned to NWAS by CHOC until 20.43 hours .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass full and accurate information between NWAS and CHOC
Wider context from the report “As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC.
(1) I found that the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused . The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation . I was concerned that full and accurate information was therefore not passing between NWAS and CHOC .
(2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the flow of information between CHOC and NWAS appeared to have confused on this issue.
At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was confirmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours.
I did not find that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours, but that the call was not returned to NWAS by CHOC until 20.43 hours.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
Verbatim wording from the response “Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur.” Source location Response from Northwest Ambulance Service
Open published response
26 Feb 2026 Yunus Hoque · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to update ambulance response categorization when a patient's condition deteriorates during a delayed response View source Absence of a follow-up communication system for significant unforeseen ambulance delays 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
Yunus Hoque · 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
Yunus Hoque, aged 13, became increasingly unwell with a viral infection and Group A streptococcal infection before suffering respiratory and cardiac arrest after a delayed ambulance response. The principal concern was that, when an ambulance response is significantly delayed beyond the time indicated to the caller, there was no follow-up communication to reassess the patient, inform the caller of the delay, or identify deterioration requiring a more urgent response.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update ambulance response categorization when a patient's condition deteriorates during a delayed response
Wider context from the report “6. However, it is apparent that in circumstances where there is a significant delay over and above that indicated to the caller, there is no follow-up call or communication to indicate further delay, to confirm the status of the patient, or to suggest that alternative transport is required, if possible. Notwithstanding this, in a changing situation, a patient may deteriorate, moving from Category 2 to Category 1 and therefore requiring a more urgent response : as was apparent from the evidence at this inquest. But a patient, family member and / or carer who relies upon information already provided by the call handler, may continue to wait for an ambulance that they have been told will arrive in a given period of time, when in reality there is no likelihood of that ambulance arriving. At the same time, NWAS will be proceeding on the basis that they are dealing with a Category 2 when the case has now become a 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a follow-up communication system for significant unforeseen ambulance delays
Wider context from the report “6. However, it is apparent that in circumstances where there is a significant delay over and above that indicated to the caller, there is no follow-up call or communication to indicate further delay, to confirm the status of the patient, or to suggest that alternative transport is required, if possible . Notwithstanding this, in a changing situation, a patient may deteriorate, moving from Category 2 to Category 1 and therefore requiring a more urgent response: as was apparent from the evidence at this inquest. But a patient, family member and / or carer who relies upon information already provided by the call handler, may continue to wait for an ambulance that they have been told will arrive in a given period of time, when in reality there is no likelihood of that ambulance arriving. At the same time, NWAS will be proceeding on the basis that they are dealing with a Category 2 when the case has now become a Category 1.
” 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 Explore SMS updates for patients awaiting an ambulance or further clinical assessment.
Verbatim wording from the response “Nevertheless, I can confirm that NWAS are currently exploring the use of SMS text messaging to patients who are waiting for an ambulance or a further clinical assessment from an NWAS clinician or external provider. This work is in the initial stages but will provide improved information to our callers whilst they await a response.” Source location Response from NWAS
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 Have senior clinicians regularly review and reprioritise waiting ambulance calls according to potential deterioration and clinical need.
Verbatim wording from the response “When patients are waiting for an ambulance, I can confirm that the calls are regularly reviewed by senior clinicians” Source location Response from NWAS
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 clinician telephone triage and referrals to alternative care pathways to support ambulance availability for Category 1 and 2 patients.
Verbatim wording from the response “In addition to the above I would like to highlight that NWAS has made significant improvement in its Category 1 and 2 response times since Yunus’ death. This has been achieved by improving the number of responding ambulances available for dispatch by employing more Paramedics and Emergency Medical Technicians. We have also increased the number of clinicians telephoning patients to complete a full clinical triage and referring into alternative pathways of care. This enables our responding ambulances to attend to our most critically unwell patients who require a Category 1 or 2 response.” Source location Response from NWAS
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 interim care and worsening-condition advice before closing ambulance calls, enabling callers to seek reassessment when circumstances change.
Verbatim wording from the response “However, prior to the closure of each call, we provide interim care advice which gives the caller advice on how to care for the patient until the ambulance arrives. Full worsening advice is also provided, advising the caller to contact 999 straight away if there are any changes in the condition of the patient, if they are worried about the patient, or if they have any other concerns. This creates the opportunity for the patient’s condition to be re-triaged and the appropriate categorisation to be elicited for their symptoms and condition.” Source location Response from NWAS
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 Finite resources prevent NWAS from providing callback updates because this would reduce capacity to answer other 999 calls and provide essential information.
Verbatim wording from the response “Unfortunately, this does not mean that we are able to provide an exact time of arrival for an ambulance, due to constraints on demand and the requirement to dispatch ambulances to the most critical patients in order of need. The reality is, with the finite resources available to the Trust, if NWAS were to carry out call-backs to patients to update them on unexpected changes to their estimated time of arrival, it would reduce our capacity to answer 999 calls for other patients and to provide essential information to callers.” Source location Response from NWAS
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 NWAS considers accurate estimates, worsening advice, clinical oversight and reprioritisation the most effective response to prolonged ambulance waits.
Verbatim wording from the response “However, prior to the closure of each call, we provide interim care advice which gives the caller advice on how to care for the patient until the ambulance arrives. Full worsening advice is also provided, advising the caller to contact 999 straight away if there are any changes in the condition of the patient, if they are worried about the patient, or if they have any other concerns. This creates the opportunity for the patient’s condition to be re-triaged and the appropriate categorisation to be elicited for their symptoms and condition.” Source location Response from NWAS
Open published response
Concerns raised 4 Ineffective investigation of deaths of detained patients View source Lack of coordinated planning for least-distressing patient transport View source Ineffective learning from deaths of detained patients View source Ineffective communication between police and ambulance services during transport assistance 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
Masood Hamid · 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
Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983 . As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated planning for least-distressing patient transport
Wider context from the report “1. There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital . This in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective learning from deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983. As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between police and ambulance services during transport assistance
Wider context from the report “3. There was ineffective communication between GMP and NWAS between 21:28 hours and 23:45 which delayed the deployment of officers to assist NWAS staff with the transportation of the deceased. This delay meant a prolonged period of distress and agitation which contributed to the stress placed on the deceased.
” Open source report
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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 Existing NWAS-GMP protocols and established communication arrangements are presented as effective for managing cooperation and transport of mental health patients.
Verbatim wording from the response “Due to the concerns you raised regarding communication with Greater Manchester Police (“GMP”), the Trust’s Mental Health Liaison Lead contacted GMP to review this further. There is a joint protocol in place between NWAS and GMP which contains Guidance on ‘Transporting Mental Health Patients’ which governs the way our respective organisations work together. I enclose a copy of the protocol for your consideration, and within section 4.5 it outlines the roles for NWAS staff in these types of circumstances, and also the role of GMP in terms of their” Source location Response from North West 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 GMP is responsible for addressing the incorrect individual police decision not to attend and support NWAS.
Verbatim wording from the response “Unfortunately, having liaised with GMP regarding Mr Hamid’s case, there is an acceptance that the individual Police decision to close the incident and not attend to support NWAS was incorrect on this occasion, and not in line with the agreed protocol. I understand GMP are taking action in relation to this and will be writing to you further in that regard.” Source location Response from North West Ambulance Service NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NWAS disputes that communication was ineffective, stating communication was good and the delay resulted from an individual incorrect police decision.
Verbatim wording from the response “Unfortunately, having liaised with GMP regarding Mr Hamid’s case, there is an acceptance that the individual Police decision to close the incident and not attend to support NWAS was incorrect on this occasion, and not in line with the agreed protocol. I understand GMP are taking action in relation to this and will be writing to you further in that regard.” Source location Response from North West Ambulance Service NHS Trust
Open published response
30 Jun 2025 Thomas Raymond Mallinson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 6 Lack of clear responsibility for care of patients during illness View source Failure to notify NWAS when referred emergency calls remain unresolved View source Overcomplexity of the care system obscuring urgent care needs View source Insufficient overnight capacity to triage waiting calls View source Failure to alert call handlers to recent same-condition contacts View source Failure to alert control when transferred emergency cases remain unresolved View source See 3 more concerns
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
Thomas Raymond Mallinson · 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
Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify NWAS when referred emergency calls remain unresolved
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them . As referred to above -where does responsibility lie?
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Overcomplexity of the care system obscuring urgent care needs
Wider context from the report “(4) To ████████, Secretary of State for Health.
In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself, and I remarked that I felt Thomas "had fallen through an overcomplex system and was indeed neglected". I am aware that you are hoping to develop a 10 year plan for the NHS and therefore feel it my duty to highlight this case to you as an example of how overcomplexity has lost sight of a man's urgent care needs .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight capacity to triage waiting calls
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload . I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above -where does responsibility lie?
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alert call handlers to recent same-condition contacts
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alert control when transferred emergency cases remain unresolved
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with . A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
Verbatim wording from the response “There was no subsequent pass back to NWAS in Mr Mallinson's case, but if there had been NWAS also have established pathways for these circumstances.” Source location Response from North West Ambulance Services
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 Enable 111 Health Advisors to review previous calls and consider escalation when callers report prior contact.
Verbatim wording from the response “With regards to the 111 service, I can confirm whilst there is no automated alert, our experience is that the caller will inform the Health Advisor (HA) that they have previously called, and at this point the HA is able to review the previous calls and consider escalation, just as their 999 call handler colleagues are empowered to do.” Source location Response from North West Ambulance Services
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 Apply NHS Pathways structured triage and repeated assessment to identify changes in patients’ conditions and manage presenting risk.
Verbatim wording from the response “I can provide assurance that our call handling process follows the nationally recognised algorithm of questions within NHS Pathways, which is a highly regarded safe and reliable system. Where symptoms indicate a greater level of need, this will be appropriately flagged, ensuring that the patient is assessed and managed according to their presenting risk, so any changes in the patient's condition can be captured by the repeated triage that would take place on subsequent calls.” Source location Response from North West Ambulance Services
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 Generate CAD alerts and display previous-call information when patients recontact NWAS within 24 hours.
Verbatim wording from the response “When a call handler receives a call from someone who has been attended by NWAS, either face to face or over the telephone, within the previous 24 hours, an alert is automatically generated on our Computer Aided Dispatch (CAD) system. Once the patient's location is confirmed, a 'pop-up box' appears to inform the call handler that a previous call has been made to that address. If the earlier call remains open in the CAD system, a banner is also displayed to allow the call handler to view the details of that previous call. Where a call is no longer active, for example following cancellation, attendance, or onward referral (such as in Mallinson's case), the Emergency Medical Advisors (EMAs) can view the associated records for that location in the 'previous call' tab on their screen.” Source location Response from North West Ambulance Services
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 Contractual arrangements with partner organisations are considered sufficient to ensure continuity after NWAS transfers care.
Verbatim wording from the response “In Mr Mallinson's case NWAS handed over the episode of care to Cumbria Health on Call (CHOC) in line with the established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred, and the service relies on the contractual arrangements that are in place with partner organisations to ensure appropriate continuity of care.” Source location Response from North West Ambulance Services
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 NWAS cannot follow up every call after care transfers because responsibility and capacity do not extend to all transferred episodes.
Verbatim wording from the response “In Mr Mallinson's case NWAS handed over the episode of care to Cumbria Health on Call (CHOC) in line with the established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred, and the service relies on the contractual arrangements that are in place with partner organisations to ensure appropriate continuity of care.” Source location Response from North West Ambulance Services
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 999 call handlers cannot routinely review historic records during live emergencies because time-critical calls and structured algorithms limit capacity.
Verbatim wording from the response “It would not, however, be expected that call handlers review all previous calls while managing a new emergency call. The call details remain accessible in the system but, given the time-critical nature of emergency calls and the structured algorithm that must be followed, 999 call handlers would not have the capacity to explore historic records during live calls.” Source location Response from North West Ambulance Services
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 For 111 calls, existing caller disclosure and Health Advisor review arrangements are considered sufficient without an automated repeat-contact alert.
Verbatim wording from the response “With regards to the 111 service, I can confirm whilst there is no automated alert, our experience is that the caller will inform the Health Advisor (HA) that they have previously called, and at this point the HA is able to review the previous calls and consider escalation, just as their 999 call handler colleagues are empowered to do.” Source location Response from North West Ambulance Services
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 Once a referral is accepted, responsibility for the patient's care rests with the receiving provider rather than NWAS.
Verbatim wording from the response “In this case, Mr Mallinson was referred to community-based care and CHOC accepted responsibility for the referral. I understand this was confirmed by CHOC during the inquest, and there was no dispute regarding the transfer of care. Once a referral has been accepted, the duty of care then rests with the receiving provider, and NWAS' responsibility appropriately ends at that point.” Source location Response from North West Ambulance Services
Open published response
5 Jun 2025 Edward Thomas WILSON · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Failure to account for relevant heart failure history when deciding whether to administer salbutamol nebulisers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Thomas 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
Edward Thomas Wilson was attended by paramedics at home and later transported to hospital after worsening breathing difficulties; he suffered cardiac arrests during transit. The principal concern was that paramedics did not take his significant heart failure into account when administering salbutamol nebulisers, which lowered his blood pressure.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for relevant heart failure history when deciding whether to administer salbutamol nebulisers
Wider context from the report “The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson's blood pressure.
” 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 Complete a retrospective Specialist Review of the treatment and care provided to the patient.
Verbatim wording from the response “Upon receipt of the Regulation 28 report a decision was made to undertake a retrospective Specialist Review into the treatment and care provided to Mr Wilson. NWAS was not aware of any concerns regarding Mr Wilson’s care prior to the conclusion of the inquest, and the witness statements provided did not highlight any failures in practice or procedure. NWAS was not present or represented at the inquest and did not have Interested Person status to the proceedings.” Source location Response from North West 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 Any risk arising from these national guidelines should be addressed to JRCALC rather than the ambulance service.
Verbatim wording from the response “The Specialist Review has concluded that the treatment afforded to Mr Wilson adhered wholly to the national guidelines produced by JRCALC and I hope this addresses the concerns you have raised. There were no contraindications to the use of salbutamol despite Mr Wilson’s medical history. Therefore, any risk resulting from adherence to these guidelines is born at a national scale and should be directed to JRCALC directly.” Source location Response from North West 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 Salbutamol treatment was indicated, appropriate and guideline-compliant; there were no contraindications despite the patient’s medical history.
Verbatim wording from the response “• The Specialist Review concludes that Salbutamol would have been indicated for Mr Wilson as he was suffering with expiratory wheeze associated with a lower airway cause, presumed to be infection. There was no absolute contraindication for using Salbutamol.” Source location Response from North West Ambulance Service
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists 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
Michael Sean Heath · 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
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 Implement and routinely review the Greater Manchester ‘Right Care, Right Person’ system with partner agencies to improve responses to mental health patients in crisis.
Verbatim wording from the response “The implementation of ‘Right Care, Right Person’ across the Greater Manchester area has required NWAS” Source location Response from NWAS
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 Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Verbatim wording from the response “Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.” Source location Response from NWAS
Open published response
10 Apr 2024 Paul Dow · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to escalate calls when repeated non-response may indicate loss of consciousness View source Lack of clinician involvement during emergency calls View source Failure to assign an appropriately urgent category to calls indicating a medication overdose and suicidal intent View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Dow · 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
Paul Dow died on 3 April 2023 after taking an overdose of medication while alone in a hotel room. He had indicated that the overdose might be an attempt to take his own life, but both ambulance calls were coded as category 3, with no clinician involved at the time. There were also concerns that the lack of response to three follow-up calls, potentially indicating loss of consciousness, did not lead to escalation.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate calls when repeated non-response may indicate loss of consciousness
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician involvement during emergency calls
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign an appropriately urgent category to calls indicating a medication overdose and suicidal intent
Wider context from the report “1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3.
2. There was no involvement from a clinician at the time of either call.
3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated
” 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 Route overdose and poisoning calls through Clinical Navigation for timely clinician review, escalation, further triage and welfare action when specialist triage is delayed.
Verbatim wording from the response “Since Mr Dow’s death, there have been various operational changes within the Trusts EOCs with regards to how emergency calls are dealt with.” Source location Response from North West 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 Provide extended overdose and poisoning training to clinicians in Clinical Navigation, the Clinical Support Desk and Clinical Coordination Desk, including use of TOXBASE.
Verbatim wording from the response “Training” Source location Response from North West 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 Automatic upgrading of every unanswered patient call is not feasible because it would significantly burden ambulance capacity and response-time targets.
Verbatim wording from the response “It is common for return calls from the ambulance service to patients to go unanswered. In that scenario, it is not possible for this to result in an automatic upgrading of calls. Automatically upgrading the categorisation of all calls to patients that go unanswered would have a significant impact in dispatching the ambulance service is able to provide to patients who have already been triaged at a higher priority (for example category 1 and category 2 calls) and would place a significant burden on the Trust’s wider response times for all patient incidents, such that the achieving of target response times is likely to become unachievable.” Source location Response from North West 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 NHS Pathways, rather than the ambulance trust, ultimately determines categorisation of calls triaged through its system.
Verbatim wording from the response “The categorisation of emergency 999 calls, which are triaged through the NHS Pathways system, is standardised across England in all ambulance Trusts which use the Pathways system. Whilst ambulance Trusts can (and do) provide feedback to NHS Pathways with views/opinions on call categorisation, the decision as to categorisation is ultimately a decision for NHS Pathways.” Source location Response from North West 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 did receive clinician review, including review by a Clinical Support Desk clinician and a Specialist Practitioner.
Verbatim wording from the response “At the time of these events, all category 3 and 4 calls presented in a ‘stack’ of calls in the Clinical Support Desk (‘CSD’) within the NWAS Emergency Operations Centre (‘EOC’), for review. The CSD is staffed by Senior clinicians who review all waiting category 3 and 4 calls in order to make a decision as to whether the call is appropriate for ambulance dispatch or whether further telephone triage is required.” Source location Response from North West 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 When patients do not answer return calls, existing arrangements provide ambulance dispatch and clinician-led judgement on whether categorisation should be upgraded.
Verbatim wording from the response “As set out above, when Mr Dow did not pick up the three calls made by the NWAS Specialist Practitioner, the decision was made by that clinician to dispatch an ambulance to him. This was, in and of itself, an escalation of the call, as it had initially been deemed appropriate for further telephone triage.” Source location Response from North West 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 category 3 outcomes were appropriate based on NHS Pathways information and audits of both calls.
Verbatim wording from the response “Based on the information provided by him in response to the call handler’s questioning during both 999 calls made to NWAS, the outcome elicited by NHS Pathways for Mr Dow’s 999 calls was a category 3 response.” Source location Response from North West Ambulance Service
Open published response
8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Claire Nicole Briggs · 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
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” 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 Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.
Verbatim wording from the response “As confirmed in the evidence provided by the Trust during the inquest, the JOP implementation process was recommenced with all Police partners on 6 July 2023 and involved fortnightly meetings with all parties. The aim of those meetings was to agree a standard format and wording for the JOP to be used across the North West.” Source location Response from NWAS
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 sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.
Verbatim wording from the response “We have continued to work closely with Greater Manchester Police to overcome any remaining barriers and an updated version of the JOP has now been agreed with Greater Manchester Police who are in the final stages of sign off. It is anticipated the updated version of the JOP will be implemented and “go live” across the whole North West following the next meeting with police partners, scheduled for the latter part of February 2024.” Source location Response from NWAS
Open published response
11 Jun 2023 Marlene McCabe · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 6 Failure to communicate material patient mental health information between healthcare providers View source Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses View source Lack of clinician understanding of how to make urgent referrals into the PIMHT View source Delays in assessing patients who may appear to be or are reported to be intoxicated View source Difficulty sharing information between service providers using different databases View source Inconsistent availability of access to mental health records across service providers 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
Marlene McCabe · 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
Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate material patient mental health information between healthcare providers
Wider context from the report “4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses
Wider context from the report “3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of how to make urgent referrals into the PIMHT
Wider context from the report “1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessing patients who may appear to be or are reported to be intoxicated
Wider context from the report “5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty sharing information between service providers using different databases
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent availability of access to mental health records across service providers
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult.
” Open source report
25 Nov 2022 Philip John BATTLE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 4 Unavailability of commissioned mental-health crisis intervention resources View source Failure of ambulance triage to identify a person who could check the caller’s safety View source Failure of ambulance triage to assess presenting mental-health and self-harm risks View source Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources 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
Philip John BATTLE · 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 John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and health services.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of commissioned mental-health crisis intervention resources
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage to identify a person who could check the caller’s safety
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety . Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative . Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage to assess presenting mental-health and self-harm risks
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” Open source report
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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 A shared mental health response vehicle is not appropriate because ambulance and police services face different demands, calls, triage and dispatch processes.
Verbatim wording from the response “NWAS and Merseyside Police provide each other with invaluable support and assistance on a daily basis. However, the demands faced by each service are very different, as too are the nature of the calls meaning that the call triage systems, categorisation and dispatch processes are distinct from each other. It is crucial that the respective mental health response vehicles reflect and meet the needs of the two very different services.” Source location Response from North West 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 Mental health response vehicles are health-led, with their scope and operating model agreed through a regional steering group involving ICBs and mental health trusts.
Verbatim wording from the response “The NHS Long Term plan is clear in its recommendation that the response to mental health problems (including response vehicles) is to be health led as they are health related issues. In the financial year ending 2022/23, NHSE released an amount of capital funding for which ambulance trusts, in partnership with their regional Integrated Care Board (“ICB”) and local mental health trusts, have tendered in order to purchase the mental health response vehicles. The staffing for such response vehicles is separately funded through the Mental Health Investment Standards, which is attached to the NHS Long Term Plan.” Source location Response from North West Ambulance Service
Open published response
20 Sep 2021 Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure to provide care and supervision while awaiting assessment 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.
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AI-generated summary
Uyapo Theodore Hayunga-Macha · 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
Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care and supervision while awaiting assessment
Wider context from the report “On 3 December 2020 Merseyside Police were called to Theo where it was apparent that he was suffering from poor mental health. An ambulance was called and Theo agreed to be taken to Arrowe Park Hospital. It is reported that whilst waiting for Triage that he left without being seen.
Why was he not being looked after? And why was he left alone when waiting for assessment?
” Open source report
Concerns raised 4 Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS View source Failure to ensure that referrals to mental health services are received and traceable View source Failure to provide Approved Mental Health Practitioners with full information about relevant mental-health contacts View source Failure to communicate relevant mental-health contacts, assessments and referrals to General Practitioners 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
Jason Pendlebury · 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
Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and risk.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that referrals to mental health services are received and traceable
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Approved Mental Health Practitioners with full information about relevant mental-health contacts
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant mental-health contacts, assessments and referrals to General Practitioners
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 Operate the Greater Manchester Clinical Assessment Service referral pathway, including NWAS identification and clinical review of eligible Category 3 and 4 mental health incidents.
Verbatim wording from the response “The Greater Manchester Clinical Assessment Service (CAS) was piloted from March-June 2019 and re-commissioned from November 2019-July 2020. In April 2020, mental health providers joined the CAS and it went live with referrals for clinically triaged patients who call” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
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 Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.
Verbatim wording from the response “The Trust jointly chaired a task and finish group with GMP, which was set up last year in response to a Regulation 28 report issued by Ms Joanne Kearsley in December 2018 to Greater Manchester Health and Social Care Partnership, Greater Manchester Combined Authority, Greater Manchester Police, North West Ambulance Service and Pennine Care NHS Foundation Trust. It was agreed that enhancements to the response around concern for welfare, and particularly risk to life, must be applied on a pan-GM basis, therefore Greater Manchester Mental Health NHS Foundation Trust and North West Boroughs Healthcare NHS Foundation Trust are also partners, despite not being involved in the specific case in question.” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
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 Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.
Verbatim wording from the response “The task and finish group has drawn together a pan-GM protocol for responding to ‘risk to life’ where it presents as a result of mental health to blue light services to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk and to promote communication and escalation at the first point that a common understanding may falter.” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
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 Send automatic Post Event Messages to GPs for patients referred or discharged with self-care advice without an ambulance response.
Verbatim wording from the response “With regards to communication with Mr Pendlebury’s GP, Mr Pendlebury was advised to contact his GP and on one call he stated he was due to visit his GP therefore information was not sent separately by the clinicians. The process within NWAS has now changed. The Adastra system now ensures that all patients who are referred or discharged with self-care” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
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 COVID-19 response demands and changing mental health services prevented organisations from fully operationalising the pan-Greater Manchester protocol at that time.
Verbatim wording from the response “This referral process was only due to go live in 2021, but has been brought forward in light of the current COVID-19 pandemic. The pandemic has otherwise impacted the ability of the respective organisations to operationalise the pan-GM protocol, with regards to the time commitment required and the fact that the system is in a state of flux, with significant changes being seen across mental health services. All organisations remain in a response phase to COVID-19 and a period of stability will be required for each organisation to re-assess the protocol.” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
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 Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.
Verbatim wording from the response “When an NWAS mental health nurse carries out a telephone assessment, they would only be aware of a previous assessment by GMP or previous calls to GMP if this is communicated to NWAS by the police and documented by the call taker. GMP, and indeed any police force or emergency service, would be expected to share any information they felt to be pertinent. Once a clinician has completed an assessment, or returned the incident to dispatch if unable to carry out a triage, NWAS would not be made aware of any further updates from GMP as the clinicians no longer have sight of the incident.” Source location 2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Open published response
24 Sep 2019 Muhammed Saif Abdul Haleem · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to maintain current information for immediate guidance to paramedics View source Lack of communication of existing DNA-CPRs or Advance Care Plans between community paediatric teams and emergency services View source Failure to ensure immediate guidance is known to and supported by clinicians 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
Muhammed Saif Abdul Haleem · 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
Muhammed Saif Abdul Haleem was 13 years old and had a severe, life-limiting neurological condition. He became unresponsive at home on 8 December 2018, was found in asystole, and died after resuscitation efforts were terminated; the principal concern was that an outdated DNA-CPR document had remained on the emergency service system for seven years without the knowledge or support of the clinicians involved in his care.
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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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain current information for immediate guidance to paramedics
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication of existing DNA-CPRs or Advance Care Plans between community paediatric teams and emergency services
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate guidance is known to and supported by clinicians
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” Open source report
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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 Reviewing and communicating changes to DNA-CPR decisions remains the responsibility of the patient’s referring clinician or GP practice.
Verbatim wording from the response “The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a DNACPR is revoked, in the same way as the agreement is communicated, NWAS would expect the GP practice to communicate the change. If this does not happen, the DNA-CPR marker on the Trust system that remains in place is a warning of the potential existence of a DNA-CPR, which directs the clinician to look for a paper copy of the DNA-CPR when on scene. NWAS policy stipulates the commencement of resuscitation until information can be confirmed. NWAS should also receive requests from GP practices to remove a DNA-CPR marker when a patient has passed away.” Source location 2019-0316-Response-by-North-West-Ambulance-Service-NHS-Trust
Open published response
12 Sep 2019 William Oliver · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Delays in hospital patient handover causing prolonged ambulance unavailability View source Meal break policy causing crews to become unavailable for call allocation 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
William Oliver · 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
William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital patient handover causing prolonged ambulance unavailability
Wider context from the report “2. Turnaround times at Greater Manchester Hospitals
Another contributing factor to the decreased availability of ambulances on the 31st October - 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites. Whilst all hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester hospital, Royal Oldham, Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour. In total from the commencement of the night shift on the 31st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. The evidence from NWAS did not suggest this was significantly different to other nights or uncommon.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Meal break policy causing crews to become unavailable for call allocation
Wider context from the report “1. Meal Break Policy and Shift Rostering
During the course of the Inquest the Court heard evidence as to the demand placed on NWAS during the night of the 31st October – 1st November. Difficulties in allocating resources within the Manchester area of the North West that night had been escalated to the Regional Control and Command Centre. One of the reasons for difficulties in allocating resources was directly attributed to the Meal Break Policy. In short, the issue being that each crew has to take a 30 minute meal break within their meal break window (this being three hours after their shift starts). If the crews reach the end of their meal break window without having taken a break they are automatically stood down and are unavailable to allocate calls to. The consequences of this policy have also been highlighted in other investigations following a death. In this case there was a significant reduction in the number of vehicles able to be allocated during the time Mr Oliver had contacted NWAS. The Court heard evidence this policy has been under review for sometime and consideration has been given to staggering the shift start times, but as yet no changes have been implemented
” 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 Pilot mandatory staggered meal-break stand-downs by transferring meal-break management from dispatchers.
Verbatim wording from the response “In addition to the roster review, in July 2019 following consultation with our commissioners, the Trust commenced an executive lead review of the meal break policy which has seen the formulation of a focus group encompassing representatives from HR, operations and the medical directorate.” Source location 2019-0494-Response-by-North-West-Ambulance-Service
Open published response
14 Aug 2019 Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Lack of provision to provide updates to other emergency services during significant ambulance delays View source Lack of provision to utilise other emergency services during significant ambulance delays 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
Gladys Esme FURNIVAL (known as Esme FURNIVAL) · 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
Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of provision to provide updates to other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of provision to utilise other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them.
” Open source report
15 Jan 2019 Marie Hilda Millward Winter · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Administration of anticoagulation medication following a head injury View source Failure to restrict anticoagulation medication advice or administration involving ambulance technicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marie Hilda Millward Winter · 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
Marie Hilda Millward Winter fell at a nursing home on 19 August 2017, sustained a head injury and developed an intracranial bleed. The report states that Apixaban was administered after the fall and that this worsened the bleed and contributed to her death at hospital on 2 September 2017. The principal concern was the administration of anticoagulant medication after a head injury, reportedly on the advice of or in the presence of ambulance technicians.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Administration of anticoagulation medication following a head injury
Wider context from the report “The evidence was that the medication (Apixaban) was given to Mrs Millward Winter at Each Step Nursing Home on the advice of and/or in the presence of the Ambulance Technicians from North West Ambulance Service after she had sustained a head injury and prior to transporting her to hospital. The concern is that the administration of this anticoagulation medication on the morning of the 19th August 2017, following a head injury, worsened an internal bleed and contributed to Mrs Millward Winter’s death. It is of concern that such medication has been given when the patient has suffered a head injury (and is at risk of an internal bleed). It is of concern that the medication has been given on the advice of and/or in the presence of the ambulance technicians.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict anticoagulation medication advice or administration involving ambulance technicians
Wider context from the report “The evidence was that the medication (Apixaban) was given to Mrs Millward Winter at Each Step Nursing Home on the advice of and/or in the presence of the Ambulance Technicians from North West Ambulance Service after she had sustained a head injury and prior to transporting her to hospital. The concern is that the administration of this anticoagulation medication on the morning of the 19th August 2017, following a head injury, worsened an internal bleed and contributed to Mrs Millward Winter’s death. It is of concern that such medication has been given when the patient has suffered a head injury (and is at risk of an internal bleed). It is of concern that the medication has been given on the advice of and/or in the presence of the ambulance technicians.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advising on Apixaban and other medications beyond six authorised medications falls outside an EMT’s scope of practice.
Verbatim wording from the response “████████ recollection is that there was no discussion in relation to the administration of anti-coagulant medication for two reasons; firstly, Mrs Millward-Winter was being conveyed to the hospital because she had suffered a head injury and was taking blood thinning medication and secondly, advising on the administration of an anti-coagulant was outside of his scope of practice as an Emergency Medical Technician (EMT).” Source location 2019-0020-Response-by-North-West-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 The nursing-home nurse, rather than an EMT, was responsible for deciding which medication should be administered and when.
Verbatim wording from the response “An Advanced Paramedic has provided an overview in light of the Regulation 28 Report and has noted that Mrs Millward-Winter was resident in a nursing home. In their view, the nurse on duty at the unit would supersede an EMT in respect of which medication should be administered and at what point.” Source location 2019-0020-Response-by-North-West-Ambulance-Service-NHS-Trust
Open published response
Concerns raised 14 Failure to escalate welfare incidents to the on-call senior manager View source Lack of clarity about police powers and role for Section 136 from-home cases View source Lack of ward staff awareness of telephone restrictions affecting 111 calls View source Unavailability of an out-of-hours mental-health community response service for face-to-face assessment View source Unclear and delayed police-to-ambulance referral process for welfare concerns View source Delays in accepting and passing on welfare concerns because of confidentiality uncertainty View source Conflicting advice about which agency to contact for welfare concerns View source Failure to identify and disclose material call-handling information during investigation View source Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life View source Delays and failures in handling welfare concerns within acute inpatient psychiatric wards View source Incorrect completion of triage-system questions View source Insufficient investigation of deaths by NWAS View source Failure to provide face-to-face welfare assessment View source Mental-health telephone triage by staff with insufficient mental-health training View source See 11 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
Mr Gregory Rekowski · 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
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate welfare incidents to the on-call senior manager
Wider context from the report “No-one considered, at any stage the escalation of this incident to the on-call Senior manager when they were having difficulties contacting the emergency services or when GMP had provided the advice to contact NWAS.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about police powers and role for Section 136 from-home cases
Wider context from the report “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst other agencies .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward staff awareness of telephone restrictions affecting 111 calls
Wider context from the report “Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours mental-health community response service for face-to-face assessment
Wider context from the report “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours . The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments . The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear and delayed police-to-ambulance referral process for welfare concerns
Wider context from the report “In this case GMP did not call NWAS and asked the nurses to contact NWAS . The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with . This also led to a delay in the call being made .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in accepting and passing on welfare concerns because of confidentiality uncertainty
Wider context from the report “The Court heard the calls between NK and NWAS. Advice was provided to NK that a concern for welfare could not be taken by them due to a potential “breach of confidentiality” . This led to a further delay in this concern for welfare call being passed to NWAS.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Conflicting advice about which agency to contact for welfare concerns
Wider context from the report “Evidence was heard from the Inpatient Services Manager of PCT of their understanding, that the Police are the organisation to call in relation to concerns for welfare (regarding risk to life). The Court heard PCT are still advised the police are the contact . In addition this the advice within the acute trusts.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and disclose material call-handling information during investigation
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case. It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life
Wider context from the report “It was clear to the Court from all Senior Managers that there was a distinct lack of understanding across all three agencies of each agencies roles/responsibilities, systems of working and current practices in relation to concerns for welfare involving risk to life (not immediate to someone in the process of harming themselves). The evidence to the Court was of a confused picture across Greater Manchester with no clear guidance as to how to deal with such matters. Moreover it was apparent there is no documented GM wide process to allow staff on the ground clear information as to how to deal with such matters.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in handling welfare concerns within acute inpatient psychiatric wards
Wider context from the report “The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this , given they were working on an acute in-patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had initially been provided.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect completion of triage-system questions
Wider context from the report “The Court heard how the call was graded as a Grade 3 however when taken through the evidence in Court several questions on the triage system had been incorrectly completed .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient investigation of deaths by NWAS
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case . It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face welfare assessment
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted . Moreover the telephone triage call was conducted by a RGN who had limited mental health training.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Mental-health telephone triage by staff with insufficient mental-health training
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted. Moreover the telephone triage call was conducted by a RGN who had limited mental health training .
” Open source report
4 Sep 2017 Anthony William McCormack · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 4 Failure of ambulance services to meet nationally set emergency response-time targets View source Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR View source Inadequate procedures for responding when the Tempus system is unable to provide assistance View source Insufficient paramedic staffing to provide Advanced Life Support at Manchester Airport View source See 1 more concern
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
Anthony William McCormack · 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
Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance services to meet nationally set emergency response-time targets
Wider context from the report “• I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources in November 2015 (for provision of more ambulances and recruitment of an additional 400 staff) I was also informed since April 2017 none of the nationally set targets have been met by any ambulance trust in England and Wales namely, a Red 1 response within 8 minutes 75% of the time, Red 2 within 19 minutes 95% of the time, I was also informed that there has been a massive increase of calls to 999 with consequent impact on response times and delays in ambulance turnaround at hospitals.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
Wider context from the report “• The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate procedures for responding when the Tempus system is unable to provide assistance
Wider context from the report “• The adequacy and effectiveness of the procedures followed by Emirates staff in the event that the Tempus system is unable to provide assistance which was the case here.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient paramedic staffing to provide Advanced Life Support at Manchester Airport
Wider context from the report “• Consequent on the above and in this specific case there was only one paramedic on duty at any one time for the Manchester Airport . Such paramedic being required to carry out Basic Life Support alone and unable to start Advanced Life Support .
” Open source report
28 Jun 2017 David Michael Lee · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to escalate the urgency of requirements for medical assistance View source Lack of training on when to terminate calls with patients View source Lack of circulation of call termination guidance to call handling staff View source Failure to appropriately determine when to terminate calls with patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Michael Lee · 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
David Michael Lee was found unresponsive at home on 18 February 2017 after taking a considerable quantity of diphenhydramine and telling the emergency call handler about this during a 999 call. The call was terminated approximately 30 minutes in, and the report identified a missed opportunity to escalate the response before he became unconscious and died prior to the ambulance’s arrival.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate the urgency of requirements for medical assistance
Wider context from the report “That the call was inappropriately terminated and that this may continue in the future.
That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated .
Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion.
That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on when to terminate calls with patients
Wider context from the report “That the call was inappropriately terminated and that this may continue in the future.
That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated.
Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion.
That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of circulation of call termination guidance to call handling staff
Wider context from the report “That the call was inappropriately terminated and that this may continue in the future.
That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated.
Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient . Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion.
That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately determine when to terminate calls with patients
Wider context from the report “That the call was inappropriately terminated and that this may continue in the future .
That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated.
Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion .
That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients.
” 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 Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.
Verbatim wording from the response “EOC Supervisors have subsequently conducted one to one briefings with all call takers in all three EOCs to discuss the guidance and ensure that the practice of terminating calls is fully understood. All call takers are required to provide their signature to confirm that they have read and understood the guidance and its use.” Source location 2017-0432
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 Revise the call-termination guidance and circulate it to all EOC supervisors.
Verbatim wording from the response “Following the inquest the Trust have revised the relevant guidance in respect of incidents where call takers should remain on the line and have circulated this to all EOC Supervisors, with the following key points emphasized as direct learning from this case:” Source location 2017-0432
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 an incident-based case study and use it in scheduled training and workshops for new and existing call takers.
Verbatim wording from the response “To ensure further Trust wide learning, the Trust’s Legal Department are to produce a case study based on this incident and the appropriate use of call terminations, which will be used in scheduled training sessions/workshops across all EOC’s for new and existing call takers; again to reinforce the practices that should be followed in situations such as this.” Source location 2017-0432
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 a reminder system to prompt periodic recirculation of call-termination guidance to call takers.
Verbatim wording from the response “To ensure that the guidance is re-circulated to all call takers at appropriate periodic intervals, the Trust’s Operations Director has also put in place a system whereby he will be periodically reminded to request that the EOC Management team complete the above recirculation process, thus ensuring all call takers are regularly reminded of the practices regarding call termination.” Source location 2017-0432
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 emergency call was processed correctly and received the correct response code based on the information provided.
Verbatim wording from the response “I am advised that at the inquest, EOC Deputy Sector Manager Angela Lee gave evidence to the Coroner that the emergency call had been audited and it had been established that it had been processed correctly based on the information given to the call taker and the correct response code was obtained. The call taker stayed on the line with Mr Lee for 30 minutes, however due to Mr Lee telling the call taker that he was starting to feel drowsy, the call taker should have stayed on the line with him until the emergency ambulance arrived. Ms Lee confirmed in evidence that this was an individual error and that the call taker has undertaken a reflective learning exercise in order to identify the error made and reflect on her practice for the future.” Source location 2017-0432
Open published response
24 Aug 2016 Joyce Mary Ravenhill · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of an operational policy for communicating urgent doctor’s appointment needs between triage nurses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joyce Mary Ravenhill · 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
Joyce Mary Ravenhill became ill with abdominal pain and vomiting on Christmas Day 2015, was not given an earlier out-of-hours doctor appointment after two triage assessments, and was later found to have an incarcerated femoral hernia causing intestinal obstruction. She underwent surgery but died on 2 January 2016; the principal concern was that there was no facility or operational policy to communicate the urgency of the first triage assessment to the second triage nurse.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an operational policy for communicating urgent doctor’s appointment needs between triage nurses
Wider context from the report “Although a summary of the first triage assessment on 26th December 2015 was available to the second triage nurse, there was no facility / operational policy whereby the simple fact that the deceased needed an urgent doctor’s appointment could be effectively communicated by the first triage nurse to the second , all information and communication being automatically electronically generated .
” 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 Apply a procedure requiring staff to manually record attempted but unavailable appointment bookings.
Verbatim wording from the response “At NWAS a procedure has been applied for all staff to manually note where an appointment booking has been attempted, but found not to be possible.” Source location 2016-0303-Response-by-North-West-Ambulance-Service-NHS-Trust
Open published response
18 May 2016 Christopher Philip Fields · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to safeguard an injured or intoxicated vulnerable person before police departure View source Failure to protect a witness from an assailant during police information gathering View source Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients View source Delays in ambulance response to coded emergency calls 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
Christopher Philip Fields · 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
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safeguard an injured or intoxicated vulnerable person before police departure
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived . Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner , why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated , why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found ?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to protect a witness from an assailant during police information gathering
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
Wider context from the report “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response , suggests that the algorithms used for coding are not accurate and not fit for purpose . In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied . (NWAS, SECRETARY OF STATE and NHS ENGLAND)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to coded emergency calls
Wider context from the report “2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes . In the event, the vehicle did not arrive for 2 hours 8 minutes . Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS)
” 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 Explore ways to minimise lengthy ambulance waits during high-demand periods.
Verbatim wording from the response “NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.” Source location 2016-0194-Response-by-North-West-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 Secure funding for 400 additional frontline staff and 60 new vehicles.
Verbatim wording from the response “NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.” Source location 2016-0194-Response-by-North-West-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 AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.
Verbatim wording from the response “In regards to AMPDS system, I confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s chest had been ‘concealed in’ this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response. I note that the attending police officers evidence supported that the patient was breathing, conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patient’s condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment). Furthermore this assertion was reinforced by ████████ Pathologist report which supported that the critical injury was sustained during the second assault.” Source location 2016-0194-Response-by-North-West-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 Green 2 requires attendance as soon as practicable, not necessarily within 20 minutes; the delay reflected exceptional activity and hospital turnaround pressures.
Verbatim wording from the response “Taking each point in turn, I confirm that the vehicle response time for the incident in question, was inextricably linked to the activity pressures, NWAS faced during this extremely challenging winter period. Despite winter weather contingency planning, activity within the Greater Manchester area saw an unexpected 22% increase, which was directly compounded by significant hospital turnaround pressures faced at Stepping Hill, North Manchester and Oldham.” Source location 2016-0194-Response-by-North-West-Ambulance-Service
Open published response
25 Nov 2015 Thomas Anthony Collins · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to accurately record the professional identity of the clinician who assessed the patient View source Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision View source Failure to establish whether a patient fall was unwitnessed and its force and details View source Failure to ascertain clinically significant chest symptoms from care staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Anthony Collins · 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
Thomas Anthony Collins lived in a care home and fell on 22 June 2015, sustaining chest injuries. He was not admitted to hospital at that time, was later admitted on 25 June, and died on 15 July 2015 after treatment for complications including sepsis, pneumonia and respiratory distress. The report raised concerns about paramedic decision-making and the GP’s assessment, including failures to recognise the seriousness of the injury and signs of a flail chest.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record the professional identity of the clinician who assessed the patient
Wider context from the report “2. The GP attended the patient on the 24th June and she assumed that he had been seen by a doctor on the 22nd because the record showed that he had been seen by a “practitioner”. In fact he had only been seen by the paramedic . This assumption very much detrimentally influenced her subsequent decision making.(Haughton Thornley Medical Centres)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision
Wider context from the report “1. The attending paramedic lacked the confidence to make a clinical decision, which I accept can happen, but he then contacted the Out of Hours doctors who had no knowledge of the patient, rather than his own GP Practice . When, in what circumstances, should a paramedic seek the advice of a doctor who is not in attendance, as to whether the patient is to be taken to hospital?(NWAS)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether a patient fall was unwitnessed and its force and details
Wider context from the report “3. On the attendance on the 24th, the doctor noted that the patient had had a fall, but she did not realise it was an unwitnessed fall, so the force and detail thereof was not known by anyone . She noted that the patient found it “was too painful for him to move or to sleep”, and she said it was “evident that he was in agony with pain for him to turn in bed” (sic). She did not ascertain from the care staff that the patient’s chest was “pulsating when breathing”, a classic sign of a flail chest. She conceded that facing the same situation now, she would have admitted him to hospital. This is clearly an area where further training is required.(Haughton Thornley Medical Centres)
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ascertain clinically significant chest symptoms from care staff
Wider context from the report “3. On the attendance on the 24th, the doctor noted that the patient had had a fall, but she did not realise it was an unwitnessed fall, so the force and detail thereof was not known by anyone. She noted that the patient found it “was too painful for him to move or to sleep”, and she said it was “evident that he was in agony with pain for him to turn in bed” (sic). She did not ascertain from the care staff that the patient’s chest was “pulsating when breathing”, a classic sign of a flail chest . She conceded that facing the same situation now, she would have admitted him to hospital. This is clearly an area where further training is required.(Haughton Thornley Medical Centres)
” Open source report
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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 existing evidence-based Acute Visiting Service referral system is considered sufficient, rather than relying on patients’ own GPs for timely clinical advice.
Verbatim wording from the response “I confirm that NWAS Paramedics perform a clinical assessment of the patient and then apply a clinical algorithm called ‘Paramedic Pathfinder’. The algorithm is used by a Paramedic to ensure the sickest patients receive rapid care and transport to the Emergency Department using an evidence-based process. The algorithm allows the Paramedic to identify patients who would benefit from clinical assessment and care at home before a decision is made to transport to hospital. The algorithm identifies a cohort of patients clinically safe to wait up to 2 hours for a further, more bespoke clinical assessment (ref: Emerg Med J published online October 7, 2013 Clinical Navigation For Beginners: clinical utility and safety of the Paramedic Pathfinder).” Source location 2015-0469-Response-by-North-West-Ambulance-Service-NHS-Trust
Open published response
10 Jul 2015 Colin Moulton · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma View source Failure to notify the hospital trust of ambulance presence within hospital grounds View source Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma 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.
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AI-generated summary
Colin Moulton · 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
Colin Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
Wider context from the report “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse . Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the hospital trust of ambulance presence within hospital grounds
Wider context from the report “2. At approximately 5pm on the 13th February 2013, a number of administrative staff, whilst en-route home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to be ‘ in difficulty’. One of the staff members called for the assistance of an ambulance which duly attended and a paramedics on board apparently were unable to locate Mr Moulton. Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware. The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital Trusts might be notified in such circumstances.
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma
Wider context from the report “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented . It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse.
” Open source report
Concerns raised 2 Failure to routinely hand over ambulance-obtained ECG traces to A&E staff View source Failure to record ECG findings and relevant features in A&E handover notes 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
David Anthony Ince · 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
David Anthony Ince was admitted to Royal Preston Hospital after collapsing at home and was discharged in the early hours. Shortly after returning home, he suffered a cardiac arrest and died despite readmission to hospital. Concerns were raised that an ECG recorded by ambulance staff was not documented in the A&E handover and that ECG traces were not routinely handed over to A&E staff.
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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely hand over ambulance-obtained ECG traces to A&E staff
Wider context from the report “(1) In the course of the Inquest hearing, it became apparent that the NWAS electronic record referred to an ECG having been carried out on Mr Ince by the ambulance staff at 11.35pm, prior to his first admission to A&E. However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personnel on arrival at RPH, and no ECG trace was handed over or seen by A&E staff .
(2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department .
” 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 West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record ECG findings and relevant features in A&E handover notes
Wider context from the report “(1) In the course of the Inquest hearing, it became apparent that the NWAS electronic record referred to an ECG having been carried out on Mr Ince by the ambulance staff at 11.35pm, prior to his first admission to A&E. However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personnel on arrival at RPH , and no ECG trace was handed over or seen by A&E staff.
(2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department.
” 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