9 Sep 2014 ROSALIND ANN ADSHEAD · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Insufficient ambulance availability during normal working hours View source Failure to avoid transferring severely ill patients in the early hours of the morning 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
ROSALIND ANN ADSHEAD · 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
Rosalind Ann Adshead had previously undergone a total gastrectomy and was later found to have severe adhesions causing strictures. During treatment for an anastomotic leak, she was transferred between hospitals in the early hours of 21 March 2014 while severely ill. Concern was raised that the timing of the transfer was unsafe and added anxiety and distress, and that ambulance shortages during normal working hours were not a valid justification.
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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 Insufficient ambulance availability during normal working hours
Wider context from the report “During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning”, that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse” .
” 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 avoid transferring severely ill patients in the early hours of the morning
Wider context from the report “During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning” , that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse”.
” Open source report
10 Apr 2014 Terence Norbert Dooley · Prevention of Future Deaths report Manchester City
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Concerns raised 4 Delays in responding to emergency calls View source Failure to communicate emergency response dispatch expectations View source Failure to assign an appropriately urgent code to a potentially fatal tablet ingestion View source Computer-generated emergency codes failing to accurately convey urgency 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
Terence Norbert Dooley · 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
Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.
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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 Delays in responding to emergency calls
Wider context from the report “2. This was an emergency and a delay of 2 hours and 38 minutes is totally unacceptable regardless of pressures on the service due to Halloween.
” 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 emergency response dispatch expectations
Wider context from the report “3. There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North West Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign an appropriately urgent code to a potentially fatal tablet ingestion
Wider context from the report “1. Despite the fact that each different tablet could be fatal on its own, let alone together, this call was given a code green .
” 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 Computer-generated emergency codes failing to accurately convey urgency
Wider context from the report “4. The computer generated codes are misleading. One dash is one too many when it should have, and could have been avoided.
” 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 Implement Emergency Operations Centre Procedure 0006 to reallocate resources from lower-priority to higher-priority incidents during periods of high demand.
Verbatim wording from the response “NWAS has a finite number of vehicles available at any one time and are aware that demand for vehicles fluctuates. We are acutely aware of the importance of delivering safe patient care, are constantly striving to improve our procedures and have a number of contingency plans which can be implemented during busy periods. One such procedure is Emergency Operations Centre Procedure ECO006 (0006), which is designed to optimise patient care during periods of high demand. In these instances, a resource responding to a lower priority call may require standing down to attend an incident with a higher priority, for example:” Source location 2014-0162-Response-by-North-West-Ambulance-Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Green 2 code assigned to the overdose call was correct because no immediately life-threatening symptoms were reported.
Verbatim wording from the response “During the 999 call made by Mr Dooley on 28 October 2012 he advised that he had taken an overdose of medication. The Emergency Medical Dispatcher (EMD) confirmed that Mr Dooley was conscious and breathing and the system generated a Green 2 response code. MPDS is designed to elicit priority symptoms from a caller, for example, whether the patient is alert, conscious and breathing. If a patient has a compromised airway or is in cardiac arrest the system recognises that they require immediate, life sustaining, treatment and will generate a Red response code. Had Mr Dooley indicated any of these priority symptoms MPDS would have generated a higher response code.” Source location 2014-0162-Response-by-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 computer-generated MPDS codes were not misleading because their meaning and generation were explained in evidence at the inquest.
Verbatim wording from the response “Computer generated codes” Source location 2014-0162-Response-by-North-West-Ambulance-Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There was no lack of communication because the dispatcher explained the high demand and advised calling back if the patient's condition worsened.
Verbatim wording from the response ““There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes.”” Source location 2014-0162-Response-by-North-West-Ambulance-Service
Open published response
Concerns raised 1 Lack of control and restraint training for ambulance service personnel 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
Caroline Louise Pilkington · 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
Caroline Louise Pilkington was found apparently suffering from a fit at home on 25 April 2013 and required restraint to be removed safely, with police assistance called because ambulance personnel were not trained in control and restraint techniques. The inquest concluded that her death was due to an accident, with the medical cause recorded as propranolol toxicity. The report raised concerns that involving police in such situations could result in clinically untrained officers dealing with unwell patients and could delay removal to hospital, potentially causing harm.
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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 control and restraint training for ambulance service personnel
Wider context from the report “North West Ambulance Service personnel are not trained in control and restraint techniques. Evidence was therefore given at the inquest that it was necessary for them to call the police service to assist them in dealing with patients who are unwell where the use of such techniques is required. This is so despite the fact that other clinical personnel, for example Mental Health nurses, are trained in such techniques. In the case of Miss Pilkington this resulted in three paramedics having to call for assistance from the police service. Evidence revealed that calling the police in these circumstances results in patients who are physically and/or mentally unwell being dealt with by the police service, who, although they are trained in control and restraint techniques, are not clinically trained to deal with such patients. In addition, further evidence was given that the involvement of the police service in these cases not only potentially results in inappropriate removal of police officers from their core policing duties, but also potentially results in harm to patients being caused by delaying their removal to hospital.
” 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 Training ambulance staff in advanced control and restraint is not feasible because incidents are rare and skills could not be maintained safely.
Verbatim wording from the response “NWAS believes that ambulance staff should focus on the treatment of the presenting condition of their patients. Advanced control and restraint is an extremely specialised skill, which, due to the risks involved, requires extensive training and regular practice. It would not be feasible for our staff to be trained in such techniques since situations where control and restraint is required arise very rarely. Consequently, ambulance staff would not be able to maintain the skills at the necessary level to ensure appropriate patient care. We believe this has the potential to compromise, rather than improve, the safety of patients.” Source location 2014-0269-Response-by-North-West-Ambulance-Service
Open published response
6 Dec 2013 Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Insufficient paediatric first aid training among nursery staff View source Failure of ambulance call-takers to correctly assess breathing and triage calls View source Lapsed first aid certification among staff 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
Millie Elizabeth Josephine Thompson · 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
Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.
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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 Insufficient paediatric first aid training among nursery staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training , and that there is a need for specialist training when confronted with certain medical conditions affecting very young children . Other members of staff had general First Aid training but this appears to have been less useful in the circumstances .
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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-takers to correctly assess breathing and triage calls
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated .
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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 Lapsed first aid certification among staff
Wider context from the report “During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time , so that although they had undergone the training it now needed updating .
The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.
I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.
” 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 Require Emergency Medical Dispatchers to provide continuing-education and audit-review evidence to maintain certification.
Verbatim wording from the response “All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.” Source location 2013-0356-Response-by-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 Provide all Emergency Medical Dispatchers with a six-week training course covering procedures, call taking, first aid, paediatric resuscitation and AMPDS.
Verbatim wording from the response “All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.” Source location 2013-0356-Response-by-North-West-Ambulance-Service
Open published response
9 Sep 2013 Martin Daffydd Barker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby View source Lack of ambulance crew access to coded hospital entrance keypads View source Failure to maintain continuous staffing of resuscitation receptions 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
Martin Daffydd Barker · 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
Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.
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 national guidance and routing for independent providers to pre-alert hospitals and place them on standby
Wider context from the report “1. There appears to be no national guidance on how independent national providers of medical services (particularly those covering large scale public events) can put NHS hospitals on standby for incoming urgent patients , something which is normal procedure for the regional ambulance services.
2. There is confusion as to whether the independent providers should place a call to the regional ambulance services who would then act as “gatekeeper” in forwarding this information to the respective hospital.
3. Without clear guidance there is a risk that the most critically ill people who are being transported to hospital are at risk as the hospitals have received no pre-alert, have not had the opportunity to place teams on standby and are not expecting their arrival .
” 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 ambulance crew access to coded hospital entrance keypads
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to .
” 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 maintain continuous staffing of resuscitation receptions
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to.
” 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 Hospitals and private ambulance providers must determine whether hospital standby numbers are shared.
Verbatim wording from the response “In relation to the day to day operation of private ambulance services, it is our position that NWAS should not, and cannot be, the “gatekeeper” for NHS hospital standby numbers. These numbers are owned by the hospitals and it is a matter between them and MMS, or any other private ambulance service providers, as to whether or not the number is shared. We submit the guidance from the Department of Health may assist in relation to these matters.” Source location 2013-0226-Response-by-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 NWAS should not and cannot act as gatekeeper for NHS hospital standby numbers.
Verbatim wording from the response “In relation to the day to day operation of private ambulance services, it is our position that NWAS should not, and cannot be, the “gatekeeper” for NHS hospital standby numbers. These numbers are owned by the hospitals and it is a matter between them and MMS, or any other private ambulance service providers, as to whether or not the number is shared. We submit the guidance from the Department of Health may assist in relation to these matters.” Source location 2013-0226-Response-by-North-West-Ambulance-Service
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations