17 Nov 2025 Paolino AMICO · Prevention of Future Deaths report Essex
View report summary
Concerns raised 19 Failure to provide clear oxygen-therapy discharge planning and referral information View source Failure to review the patient before prescribing a controlled drug View source Failure to consider or plan alternative pain management during opioid overdose treatment View source Failure to accurately record medication administration View source Non-mandatory medicines-administration refresher training for nurses View source Failure to escalate medication concerns to appropriately senior clinicians View source Failure to make an emergency call for an unresponsive patient View source Failure of medicines-administration training to support recognition of inappropriate MST prescribing View source Failure to administer MST at the prescribed frequency View source Failure to provide opioid reversal in accordance with applicable guidance View source Failure to administer prescribed medication View source Failure to identify prescription errors and prior doses during controlled-drug checks View source Failure to implement the local recommendation to include mandatory medicines-administration refresher training View source Failure to scrutinise prescribed medication and medication-system information View source Failure to communicate overnight deterioration and family medication concerns to the on-call doctor View source Failure to provide oxygen flow meeting patient requirements at discharge View source Delay and inappropriate escalation of a high NEWS score View source Failure to make an emergency call after escalation of concerns View source Out-of-date PAT testing for oxygen equipment View source See 16 more concerns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
Paolino AMICO · 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
Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.
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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear oxygen-therapy discharge planning and referral information
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear , and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review the patient before prescribing a controlled drug
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug .
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider or plan alternative pain management during opioid overdose treatment
Wider context from the report “(6) Mr Amico morphine overdose was partially treated:
a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued.
b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer.
c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient.
Princess Alexandra Hospital & 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record medication administration
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record . Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory medicines-administration refresher training for nurses
Wider context from the report “(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate medication concerns to appropriately senior clinicians
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to make an emergency call for an unresponsive patient
Wider context from the report “(3) Mr Amico’s NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr Amico was unresponsive even to pain from 03:00 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of medicines-administration training to support recognition of inappropriate MST prescribing
Wider context from the report “(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate . Mr Amico received 6 doses of MST in less than 24 hours instead of 2.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to administer MST at the prescribed frequency
Wider context from the report “(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate. Mr Amico received 6 doses of MST in less than 24 hours instead of 2 .
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide opioid reversal in accordance with applicable guidance
Wider context from the report “(6) Mr Amico morphine overdose was partially treated:
a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued .
b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer.
c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient.
Princess Alexandra Hospital & 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prescription errors and prior doses during controlled-drug checks
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning .
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the local recommendation to include mandatory medicines-administration refresher training
Wider context from the report “(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included .
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to scrutinise prescribed medication and medication-system information
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily . Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
Wider context from the report “(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of:
a. the deterioration in Mr Amico’s presentation during the night
b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide oxygen flow meeting patient requirements at discharge
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Delay and inappropriate escalation of a high NEWS score
Wider context from the report “(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call . The on-call doctor had not been informed of:
a. the deterioration in Mr Amico’s presentation during the night
b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST.
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to make an emergency call after escalation of concerns
Wider context from the report “(5) The on-call doctor escalated concerns immediately but not emergency call was put out .
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Out-of-date PAT testing for oxygen equipment
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date . Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” Open source report
5 Nov 2020 Ann Margaret Smith · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma 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
Ann Margaret Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ann Margaret Smith was admitted to Princess Alexandra Hospital, suffered an unwitnessed fall the following day, sustained a head injury and died four days later. The principal concern was uncertainty about managing anticoagulation after the fall, including the lack of a local protocol for patients over 65 on anticoagulants who sustain head trauma.
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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma
Wider context from the report “1. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol (part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another clinical reason eg suspected pulmonary embolus, who sustain head trauma.
” Open source report
29 Mar 2018 Matthew Luke FAULKNER · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 3 Insufficient EEAS resources for demand View source Delays in handover to hospital View source Unsustainable public demand on the EEAS 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
Matthew Luke FAULKNER · 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
Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to hospital.
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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient EEAS resources for demand
Wider context from the report “(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them .
(2) That the current position regarding demand outstripping available resources is not significantly different to that in May 2017 .
” 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in handover to hospital
Wider context from the report “(4) That there are still significant delays on hand-over to hospital , exacerbating the lack of Ambulances being available to answer emergency 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 Princess Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Unsustainable public demand on the EEAS
Wider context from the report “(3) That the demands placed on the EEAS by the public are not sustainable . With, in the region of, only 60% of ambulance attendances resulting in admission to hospital for urgent care.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations