Recipient

Recipient name withheld

First report 7 Mar 2022•Latest report 7 Mar 2022

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Mar2022
Surrey
Concerns raised14
1. Early termination of 999 call triage before completion
2. Failure to follow up a paramedic request for recategorisation with clinical discussion
3. Failure to recognise drowsiness as a new symptom requiring re-triage
1. Unavailability of clinicians for two-hour clinical review
2. Failure to distinguish persistent vomiting from initial post-injury vomiting
3. Absence of Clinical Safety Navigator management of Welfare Stack priority
4. Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling
5. Failure to obtain available healthcare professional assessment early in call handling
6. Failure to contextualise questions about worsening condition across callers
7. Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury
8. Failure to make callbacks after dropped calls and at the two-hour mark
9. Failure to keep continuous CAD records updated with changing patient information
10. Lack of policy guiding diversion of an allocated ambulance en route
11. NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
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

Josephine Celia 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

Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Early termination of 999 call triage before completion
Wider context from the report
“1. The initial early exit of the first 999 call without full triage- this results in a category 3 response. There is no reason full triage could not have continued. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow up a paramedic request for recategorisation with clinical discussion
Wider context from the report
“12. The off-duty paramedic request re categorisation was not followed and the challenge to it did not lead to a clinical discussion. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise drowsiness as a new symptom requiring re-triage
Wider context from the report
“9. When Jo was reported as drowsy, this was not considered as a new symptom and she was not re-triaged. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of clinicians for two-hour clinical review
Wider context from the report
“6. There should have been a clinical review at 2 hours. I have heard that there was not because there were not enough clinicians available. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to distinguish persistent vomiting from initial post-injury vomiting
Wider context from the report
“11. Jo’s vomiting was not the same symptom over time. Vomiting initially after a head injury is not the same as still vomiting after it two hours later. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Absence of Clinical Safety Navigator management of Welfare Stack priority
Wider context from the report
“4. There was no Clinical Safety Navigator in place to manage the Welfare Stack. This is an alert that gives an indication to those viewing the list of cases waiting for an ambulance of the priority of the call within its category. Jo’s case had a number of features which would have led to it becoming a priority within its category and potentially being upgraded: the incident was outside and therefore less safe and comfortable than waiting in a home/workplace; the day was very cold and there was a risk of hypothermia particularly as Jo was lightly dressed in gym clothes and lying on the asphalt of the car park floor and as time passed she had been waiting a long time and finally her case breached its time limit. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling
Wider context from the report
“5. At no point did a clinician have any input into the calls after the initial question from the call handler of call 1 as to whether this was major trauma or not and therefore there was no clinical assessment by SECAMBS of Jo’s condition over the following two and a half hours: she was vomiting for over two hours after the fall, she had fluctuating consciousness and was rousable to shaking and not to voice. She had had a tonic-clonic seizure and had potentially been injured by being hit by a car. She was unable to open her eyes. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain available healthcare professional assessment early in call handling
Wider context from the report
“3. An off-duty paramedic was on scene throughout and had clinical experience which was not asked for until the final 999 call when the call handler was passed to him by the second off-duty paramedic (from HART) who had arrived on scene and made the call. There has been no reason given as to why the off-duty paramedic’s assessment was not asked for earlier and I was told that there is a policy in place with reference to Health Care Professionals which has since been updated but does ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to contextualise questions about worsening condition across callers
Wider context from the report
“10. When speaking to different members of the public the questions about worsening condition were not contextualised so the caller is unable to be sure what information the call handler already has. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury
Wider context from the report
“2. London Ambulance have a different major trauma protocol to SECAMBS and the fact that Jo had been potentially hit by a car – even moving slowly- and had a head injury would have been enough for the Major Trauma protocol for London Ambulance. SECAMBS major trauma protocol was not triggered because even if she had been hit by a car it was not moving fast enough to justify a major trauma category (cat 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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to make callbacks after dropped calls and at the two-hour mark
Wider context from the report
“7. There were no callbacks made either to the caller whose call was dropped or to any of the callers at the 2 hour mark. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep continuous CAD records updated with changing patient information
Wider context from the report
“13. The continuous CAD was not kept updated with details of Jo’s condition or other useful information when each of the calls came in. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of policy guiding diversion of an allocated ambulance en route
Wider context from the report
“14. Call sign 239 was diverted to a welfare briefing after it had been allocated. There is no policy guiding making this decision after allocation has been made and the ambulance is en route. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
Wider context from the report
“8. There is a concern over the NHS Pathways tool’s ability to deal with fluctuating consciousness. This is because there is only an assessment on conscious or on unconscious so moving between the two states triggers the call handler to move into the conscious or unconscious pathway respectively but is not able to take into account fully that consciousness level is impaired or mixed. This is considered as a huge challenge to any call handler even a clinician as it then is not established if the patient is conscious or unconscious and it forces the call handler to restart triage with each change. I was told that this can ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised14

Early termination of 999 call triage before completion

Failure to follow up a paramedic request for recategorisation with clinical discussion

Failure to recognise drowsiness as a new symptom requiring re-triage

Unavailability of clinicians for two-hour clinical review

Failure to distinguish persistent vomiting from initial post-injury vomiting

Absence of Clinical Safety Navigator management of Welfare Stack priority

Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling

Failure to obtain available healthcare professional assessment early in call handling

Failure to contextualise questions about worsening condition across callers

Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury

Failure to make callbacks after dropped calls and at the two-hour mark

Failure to keep continuous CAD records updated with changing patient information

Lack of policy guiding diversion of an allocated ambulance en route

NHS Pathways tool failing to support triage of fluctuating or impaired consciousness