28 May 2021 Peggy COPEMAN · Prevention of Future Deaths report Norfolk
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Concerns raised 5 Failure to ensure transport staffing complies with the CPR training requirement View source Insufficient CPR-trained staffing for patient transport View source Failure of internal investigation to identify concerns about emergency response and CPR safety View source Failure to enable effective CPR in the patient transport vehicle View source Failure to promptly recognise and respond to respiratory distress or cardiac arrest during patient transport View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Peggy COPEMAN · 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
Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting staff.
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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 Premier Rescue Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure transport staffing complies with the CPR training requirement
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” 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 Premier Rescue Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Insufficient CPR-trained staffing for patient transport
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” 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 Premier Rescue Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigation to identify concerns about emergency response and CPR safety
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” 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 Premier Rescue Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to enable effective CPR in the patient transport vehicle
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” 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 Premier Rescue Ambulance Service Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly recognise and respond to respiratory distress or cardiac arrest during patient transport
Wider context from the report “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
” 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 Establish an authorised internal training capacity by qualifying a staff member to train others within the company.
Verbatim wording from the response “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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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 basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.
Verbatim wording from the response “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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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 a transport policy refusing patients who are not awake and responsive, requiring medical fitness confirmation and medication details for transfer risk assessment.
Verbatim wording from the response “7. Premier Rescue Ambulance Service Ltd., have now implemented a Policy that they are no longer prepared to accept for transport, patients who are not awake and responsive at the commencement of the journey. This is so they can actually assess any changes in their behaviour on the journey. They will also require a signed document from a qualified Medical Practitioner confirming a patient’s fitness to travel and also require a detailed list of medications patients are receiving so as to enable them to carry out a risk assessment as to whether it is appropriate for those patients to be transferred by Premier Rescue Ambulance Service Ltd. The detailed list of medications will be reviewed by ████████ and ████████. Those Policies have been implemented immediately.” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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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 Investigate the possibility of appointing a qualified independent assessor for future internal investigations.
Verbatim wording from the response “5. The Company regret their initial investigation did not highlight ████████
████████ or ████████ as not having CPR training. They have now revised their internal investigation procedure and they are now investigating the possibility of a qualified independent assessor carrying out such a role in the future should the need arise. In the meantime, any internal investigation pending such an appointment will be carried out by” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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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 Revise and immediately implement the internal investigation procedure, assigning interim investigations to a fully trained State Registered Nurse.
Verbatim wording from the response “4. Premier Rescue Ambulance Service Ltd., merely observe that the request to transfer Peggy Copeman was received late in the afternoon of the 15th December with a request to transfer her on the morning of the 16th December. Accepting instructions such as this in such a short timeframe has been identified by the Company as a weakness in procedures which led to two untrained staff accompanying one trained member of staff.” Source location 2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations