16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source See 2 more concerns
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AI-generated summary
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review another ambulance service’s video-assisted resuscitation guidance pilot to assess whether implementation would benefit local telephone triage.
Verbatim wording from the response “Telephone triage is a recognised challenge because the person completing the triage is unable to see the patient and / or the scene and it can be hard for a member of public to describe what they are seeing, particularly when they are inadvertently panicked by witnessing an emergency. A recent pilot of video assisted clinical guidance during resuscitation has been undertaken by another ambulance Trust within the UK. The results of this pilot have been shared with SCAS, and we are currently reviewing the results to consider whether implementing this system within SCAS would be of benefit, particularly when there is uncertainty surrounding a patient’s presentation, as there was in Adam’s case.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the computer-aided dispatch system and use the pilot outcome to inform its pre-sieve question set.
Verbatim wording from the response “The Trust is currently in the process of replacing its computer aided dispatch (CAD) system and the outcome of the above pilot will help to inform the population of pre sieve questions within the new CAD system. It is not possible to integrate them into the current system due to the limitations of its technology.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver community basic life-support training covering automated external defibrillator benefits, appropriate use and operation.
Verbatim wording from the response “To promote knowledge of life saving skills outside of an emergency, our Community Engagement Team regularly deliver basic life support training sessions within our local communities, which includes the benefits of using an automated external defibrillator (AED), when they should be used and emphasising that the devices will not deliver defibrillation to a patient unless they are in a shockable cardiac rhythm. Enclosed with this response is a document which includes links to publications of the training sessions we have provided as examples of the types of sessions that we provide.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold an initial meeting with a local football academy and agree initial progress actions for proposed joint training on collapsed-player 999 calls.
Verbatim wording from the response “As an initial step, the Trust has contacted a local football academy to discuss this proposal, and they are keen to explore this further with us. The Trust has also contacted your office and obtained the contact details for the representative from the Football Association your officers used for Adam’s inquest so that this proposal can be discussed with them.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial the Pre-Sieve Questions Project to reduce pre-sieve questioning and accelerate Nature of Call selection.
Verbatim wording from the response “The significance of using the ‘no, no, go’ approach is discussed throughout the training that we provide. This will be further supported by our ‘Pre-Sieve Questions Project’ which is being trialled in June 2026. This project will concentrate on reducing the number of pre-sieve questions asked by an ECT regarding a patient’s consciousness level and breathing rate before a Nature of Call (NOC) is selected. The aim of the project is to reduce the time that is taken to select a NOC to a maximum of 15 seconds after a 999 call is answered.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the integrated national defibrillator network to prompt callers to retrieve nearby devices and provide verbal application guidance during cardiac-arrest calls.
Verbatim wording from the response “In real time emergency situations, the national defibrillator network, The Circuit, is installed within our CAD system. When it is recognised that a patient is in cardiac arrest and there is more than one person on scene with the patient, our ECTs will be prompted to direct a caller to obtain a defibrillator which is close to the location of the incident. The ECT will then provide verbal support to the caller instructing them to apply the device and follow the instructions contained within the AED prior to the arrival of an ambulance resource.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate CPR and defibrillation education through social-media posts reaching community audiences.
Verbatim wording from the response “In addition to the face-to-face practical sessions, the Trust also engages with communities over social media platforms. Since April 2025, the Trust has shared 26 posts on our Facebook page related to cardiopulmonary resuscitation (CPR) and defibrillation, which reached an online audience of just under 1.2 million people. This included a video of a SCAS staff member carrying out CPR to the tune of ‘Golden’ from KPop Demon Hunters to capture the attention of the younger members of our community; this post alone had over 558,000 views.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen emergency call-taker training with audible agonal-breathing examples, listening-skills guidance and clinical-escalation emphasis.
Verbatim wording from the response “In response to the learning from the inquest hearing into Adam’s death and the concerns that you have raised, the Trust has strengthened the core training currently provided to our ECTs, in addition to the mandated NHS Pathways training. Additional audible examples of different types of agonal (abnormal) breathing that may be displayed have now been included as it was recognised that in this case, Adam’s presentation of agonal breathing was atypical. The importance of using effective listening skills and seeking clinical advice when there is uncertainty has also been emphasised within our core training.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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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 Pre-sieve questions cannot be integrated into the current computer-aided dispatch system because of its technological limitations.
Verbatim wording from the response “The significance of using the ‘no, no, go’ approach is discussed throughout the training that we provide. This will be further supported by our ‘Pre-Sieve Questions Project’ which is being trialled in June 2026. This project will concentrate on reducing the number of pre-sieve questions asked by an ECT regarding a patient’s consciousness level and breathing rate before a Nature of Call (NOC) is selected. The aim of the project is to reduce the time that is taken to select a NOC to a maximum of 15 seconds after a 999 call is answered.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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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 Universal instructions on AED operation cannot be cascaded because AEDs have different makes and models.
Verbatim wording from the response “To promote knowledge of life saving skills outside of an emergency, our Community Engagement Team regularly deliver basic life support training sessions within our local communities, which includes the benefits of using an automated external defibrillator (AED), when they should be used and emphasising that the devices will not deliver defibrillation to a patient unless they are in a shockable cardiac rhythm. Enclosed with this response is a document which includes links to publications of the training sessions we have provided as examples of the types of sessions that we provide.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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Concerns raised 2 Significant risk from extended ambulance waits for elderly or vulnerable Category 3 patients View source Failure to maintain ambulance availability during hospital handover delays View source
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AI-generated summary
Liliane Andree BOWDEN · 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
Liliane Andree Bowden died at Oak View Care Home on 23 September 2024 from bronchopneumonia, with vascular dementia and recent falls making substantial contributions. The inquest raised concerns about a prolonged ambulance delay following her fall, in the context of ambulance demand and hospital handover delays, particularly for elderly or vulnerable Category 3 patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant risk from extended ambulance waits for elderly or vulnerable Category 3 patients
Wider context from the report “During the course of the inquest evidence revealed matters giving rise to concern, relating to ambulance delay on a callout just under two weeks prior to Liliane Andree Bowden’s death. It is right to immediately acknowledge that the ambulance service, South Central Ambulance Service, provided me with a detailed explanation.
In this instance the initial call was at 11.40 with a second call at 13.29, a third call at 15.53 and a fourth call (seeking an estimated time of arrival of the ambulance) at 17.29. Liliane, 90, had fallen. Category 3 was called at around,13.29, category 3 was confirmed at around 16.26. A specialist paramedic was at the deceased’s bedside at 17.35 and an ambulance was requested at 18.00. At that time there was demand on the ambulance service (the Enhanced Patient Safety Procedure had been in place from 23.15 the previous night until 11.35 on the day of the call) and there were significant hospital handover delays at hospital: apparently the call centre log records up to 25 ambulances held outside hospital waiting to hand over patients that afternoon, at 18.10 there were 8 ambulances at hospital waiting to hand over patients, one of which had been waiting for 4 hours and 40’ to hand over their patient. It was estimated that an ambulance would not be available for seven hours. In the event an ambulance eventually arrived at 23.30. The response timeframe for a category 3 call is for at least 9 out of 10 calls to be within 120’.
It follows that although the Enhanced Patient Safety Procedure was activated the previous night, following deactivation of the Enhanced Patient Safety Procedure a large contingent of ambulances was taken out of action for substantial periods by handover issues. Quite apart from a repetition of such circumstances potentially affecting category 1 and 2 calls, there must be significant risk in the case of an elderly and/or vulnerable person in Category 3 having an extended wait, particularly if there has been a head injury, as is often the case.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain ambulance availability during hospital handover delays
Wider context from the report “During the course of the inquest evidence revealed matters giving rise to concern, relating to ambulance delay on a callout just under two weeks prior to Liliane Andree Bowden’s death. It is right to immediately acknowledge that the ambulance service, South Central Ambulance Service, provided me with a detailed explanation.
In this instance the initial call was at 11.40 with a second call at 13.29, a third call at 15.53 and a fourth call (seeking an estimated time of arrival of the ambulance) at 17.29. Liliane, 90, had fallen. Category 3 was called at around,13.29, category 3 was confirmed at around 16.26. A specialist paramedic was at the deceased’s bedside at 17.35 and an ambulance was requested at 18.00. At that time there was demand on the ambulance service (the Enhanced Patient Safety Procedure had been in place from 23.15 the previous night until 11.35 on the day of the call) and there were significant hospital handover delays at hospital: apparently the call centre log records up to 25 ambulances held outside hospital waiting to hand over patients that afternoon, at 18.10 there were 8 ambulances at hospital waiting to hand over patients, one of which had been waiting for 4 hours and 40’ to hand over their patient. It was estimated that an ambulance would not be available for seven hours. In the event an ambulance eventually arrived at 23.30. The response timeframe for a category 3 call is for at least 9 out of 10 calls to be within 120’.
It follows that although the Enhanced Patient Safety Procedure was activated the previous night, following deactivation of the Enhanced Patient Safety Procedure a large contingent of ambulances was taken out of action for substantial periods by handover issues. Quite apart from a repetition of such circumstances potentially affecting category 1 and 2 calls, there must be significant risk in the case of an elderly and/or vulnerable person in Category 3 having an extended wait, particularly if there has been a head injury, as is often the case.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit the 2026/27 service plan to NHS England in February.
Verbatim wording from the response “The SCAS and PHT CEO’s jointly presented the work our teams had carried out to the Association of Ambulance Chief Executives to showcase the excellent achievements in reducing handover delays. Each year we are required to submit an annual plan to NHS England on how we will deliver our services. For 2025/26, our plan included average handover times at hospitals across our geography. Each hospital was asked to sign up to the improvement and for the year to date we have delivered on or below plan across our region. There is a requirement within the next 3 years for all hospitals to reach the 15 minute handover target and have not delay over 45 minutes. We will continue to work with all hospitals to deliver these targets and we will submit our plan to NSHE in February for 26/27.” Source location Response from South Central Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with hospitals to deliver handover-time targets.
Verbatim wording from the response “The SCAS and PHT CEO’s jointly presented the work our teams had carried out to the Association of Ambulance Chief Executives to showcase the excellent achievements in reducing handover delays. Each year we are required to submit an annual plan to NHS England on how we will deliver our services. For 2025/26, our plan included average handover times at hospitals across our geography. Each hospital was asked to sign up to the improvement and for the year to date we have delivered on or below plan across our region. There is a requirement within the next 3 years for all hospitals to reach the 15 minute handover target and have not delay over 45 minutes. We will continue to work with all hospitals to deliver these targets and we will submit our plan to NSHE in February for 26/27.” Source location Response from South Central 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 relevant hospital organisation, rather than the ambulance service, has ultimate power to resolve ambulance handover-delay concerns.
Verbatim wording from the response “It is regretful that a Regulation 28 report was issued to this Trust when the source of the concern relates to a different organisation, and it is they who ultimately have the power to take action to resolve the concerns. Moving forward, we would be grateful if HM Coroner could write to the appropriate organisation in line with paragraph 9 of Chapter 16 of the Chief Coroner’s Bench Book.” Source location Response from South Central Ambulance Service
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28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
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Concerns raised 7 Delays in transferring patients from the Emergency Department into wards View source Failure to provide interim safety guidance while awaiting ambulance arrival View source Delays in ambulance-to-hospital handover View source Delays in medically trained clinician review of ambulance call information View source Delays in transferring ambulance patients into the Emergency Department View source Failure to adequately record and accurately and completely convey symptom information View source Failure to base triage category changes on evidence of clinical change or deterioration View source See 4 more concerns
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AI-generated summary
Lewis Aubrey GARFIELD · 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
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients from the Emergency Department into wards
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards , causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide interim safety guidance while awaiting ambulance arrival
Wider context from the report “c) The family complained of not being given any guidance on how to deal with the patient pending the arrival of an ambulance e.g. not to move him given the fall down the stairs .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance-to-hospital handover
Wider context from the report “d) I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes. However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours . The Trust lost 115 hours waiting to handover at Northampton over 121 hours at Kettering.
e) I heard evidence that steps are being taken to mitigate the impact of pressures in the healthcare system. University Hospitals of Northamptonshire have adopted the ‘45-minute handover’ approach. Despite this, on the day of the inquest on 27 October 2025, average handover times at Northampton General Hospital were 1 hour 11 minutes and I suspect that this will get worse during the full onset of winter pressures.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medically trained clinician review of ambulance call information
Wider context from the report “b) The first call was at around 00:44 hours but it was not until over 4 hours later at 05:05 hrs that a medically trained clinician first reviewed the facts , immediately escalating it to category 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring ambulance patients into the Emergency Department
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED , and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and accurately and completely convey symptom information
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to base triage category changes on evidence of clinical change or deterioration
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” Open source report
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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 second call was upgraded because the patient’s condition deteriorated and accurate triage information became available.
Verbatim wording from the response “I have asked the SCAS legal team to provide you with copies of call recordings for the calls that were taken so that you can be satisfied that the information captured during the call triage was accurate. It is evident from the second 999 call that there had been a change and deterioration in Mr Garfield’s condition, and he had unfortunately fallen again after the first 999 call was made. The Emergency Call Taker was also able to obtain answers to the questions” Source location Response from South Central 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 East Midlands Ambulance Service must address the clinician’s upgrade rationale and the delay before clinical review.
Verbatim wording from the response “Because the clinician who made the call to Mrs Garfield referred to within your Regulation 28 report works for East Midlands Ambulance Service SCAS are unable to comment on the call or their rationale for upgrading the call to a Category 1 ambulance response. We are also unable to comment on the time that passed before a clinician reviewed the call. East Midlands Ambulance Service will need to respond to both of these points.” Source location Response from South Central 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 Call takers advised not moving the patient unless immediately necessary and to redial 999 if concerns arose.
Verbatim wording from the response “In relation to worsening advice, our Emergency Call Taker correctly advised that Mrs Garfield and her neighbour keep a close eye on Mr Garfield and they should apply pressure to his head wound if it begins to bleed again and should not remove any objects from the wound. In addition to this, the Emergency Call Taker advised them to redial 999 if his condition changed, worsened or they had any other concerns.” Source location Response from South Central Ambulance Service
Open published response
12 Jun 2025 Oscar Michael Thomas Keenan · Prevention of Future Deaths report Oxfordshire
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Concerns raised 3 Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems View source Total reliance on an algorithm that does not direct early clinical input View source Delays and lack of direction in obtaining clinical assessment View source
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AI-generated summary
Oscar Michael Thomas Keenan · 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
Oscar was born with a pelvi-ureteric junction obstruction and later developed a bacterial infection after prescribed antibiotics were not received. On 26 June 2024, he was taken to hospital after a call to NHS 111 about breathing difficulties, was found to have sepsis, and died the same day. Concerns included inadequacies in the algorithm for assessing ill newborns, reliance on the algorithm without early clinical input, and delay or lack of direction in obtaining clinical assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Total reliance on an algorithm that does not direct early clinical input
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and lack of direction in obtaining clinical assessment
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” 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 Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
Verbatim wording from the response “NHS Pathways System Issues” Source location Response from South Central Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
Verbatim wording from the response “111 End to End Review Meetings” Source location Response from South Central Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Verbatim wording from the response “To further gauge understanding and comprehension of the content within any shared learning materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent Standard Operating Procedure (SOP) Change Notices, shared learning materials, existing SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via MS Forms which allows staff who submit incorrect answers to see explanations of the correct answer with sign posting to the source reference materials. Quick Quizzes have included questions regarding assessing a patient’s breathing in July 2024, August 2024, September 2024 and April 2025 and regarding when and how to pass a call to a clinician every month since December 2024.” Source location Response from South Central 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 Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Verbatim wording from the response “In addition to the above, our Clinical Coordination Centre (CCC) Quality Improvement Team have considered points 2 and 3 of the concerns raised and they are satisfied that there is not an inherent or recurrent issue of staff not seeking clinical advice when appropriate to do so within our call centres.” Source location Response from South Central 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 NHS England, not the Trust, is responsible for altering the NHS Pathways algorithms.
Verbatim wording from the response “As indicated at the beginning of this letter, the Trust is a user of the NHS Pathways system, and we are consequently not able to alter the algorithms contained within it, only NHS England can do this. We have therefore focused our review and response on the training that is provided to Emergency Call Takers and Health Advisors who use the NHS Pathways system and the process in place for identifying any themes or that indicate additional wider training may be required.” Source location Response from South Central Ambulance Service
Open published response
7 Apr 2025 Sandra Ann MILLARD · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Failure to apply additional caller enquiries when a person is unable to move from any position View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Ann MILLARD · 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
Sandra Ann Millard called 111 on 19 May 2024 because she was unable to move from her chair. A clinician could not reach her by telephone, no ambulance was dispatched, and she was found deceased by a neighbour the following day; the cause of death was recorded as sepsis from infected leg ulcers, with ischaemic heart disease, coronary artery atheroma and chronic kidney disease also noted. The concern was that additional enquiries and support arrangements used for people lying on the floor were not applied to people unable to move from other positions, such as a chair.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply additional caller enquiries when a person is unable to move from any position
Wider context from the report “I heard that when SCAS call takers using the NHS Pathways triage tool exit a module indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions of the caller; including whether someone else is with the caller; whether the caller can provide a number for next of kin or other person who may be able to attend the caller whilst they wait for an ambulance. This is due to the likely delay of a number of hours before an ambulance can attend.
This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair.
My concern is that the additional risks of a long lie, for example rhabdomyolysis, may well apply when someone in unable to move from any position.
SCAS agreed to change their standard operating procedures to incorporate additional enquiries in these circumstances. I am pleased that they have agreed to amend their procedures swiftly.
However this matter has wider significance and should be considered by other users of the NHS Pathways triage tool.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved staff directive requiring enhanced questioning, contact details, falls triage, position documentation, clinical referral and appropriate case closure.
Verbatim wording from the response “In response to your concerns, a change in process has now been written by ████████ in the form of a directive to staff. The changes will include:” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Writing NHS Pathways triage algorithms is outside the Trust’s responsibility, so it cannot directly change the questions asked.
Verbatim wording from the response “Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England designs and manages NHS Pathways and must consider whether the algorithm should be changed.
Verbatim wording from the response “Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.” Source location Response from South Central Ambulance Service
Open published response
3 Feb 2024 Wyllow-Raine Swinburn · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Delays in connecting 999 calls to an Emergency Call Taker View source Delays in ambulance or paramedic attendance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wyllow-Raine Swinburn · 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
Wyllow-Raine Swinburn became unresponsive at home on 30 September 2022 after being discharged from hospital the previous evening, and died in hospital that day. The concerns related to a seven-minute delay in connecting the 999 call to an emergency call taker and the 31-minute response time for the first paramedic to attend.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in connecting 999 calls to an Emergency Call Taker
Wider context from the report “The two concerns relate to, firstly, the length of time for the 999 call to be connected to a ECT (Emergency Call Taker , and secondly, the length of time for an ambulance/paramedic to attend. I fully appreciate there have been very significant demands on ambulance services including on SCAS in the past few years. I also understand, from the written and oral evidence of ████████ that multiple actions have been undertaken to improve ECT staffing and inconsistency. My primary concern is in relation to this first issue. I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times.
It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.
Given the risk associated with delayed response times, particularly in connecting to an ECT , I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance or paramedic attendance
Wider context from the report “The two concerns relate to, firstly, the length of time for the 999 call to be connected to a ECT (Emergency Call Taker, and secondly, the length of time for an ambulance/paramedic to attend . I fully appreciate there have been very significant demands on ambulance services including on SCAS in the past few years. I also understand, from the written and oral evidence of ████████ that multiple actions have been undertaken to improve ECT staffing and inconsistency. My primary concern is in relation to this first issue. I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times .
It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.
Given the risk associated with delayed response times , particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the rota review and implement the remaining new rotas.
Verbatim wording from the response “• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Isle of Wight NHS Trust to increase Emergency Call Taker numbers and availability.
Verbatim wording from the response “• We are continuing to work in partnership with the Isle of Wight NHS Trust to increase ECT numbers and availability.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the vehicle fleet to improve reliability and reduce vehicles being unavailable or breaking down during operations.
Verbatim wording from the response “• We are in the process of updating our fleet of vehicles to increase the reliability of our fleet and reduce occasions where vehicles are out of service or break down during operational use. A total of 124 new vehicles have been ordered, with 53 delivered by the end of 2024.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised recruitment and retention plans to improve staffing numbers and placement of staff in appropriate posts.
Verbatim wording from the response “• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a People Promise Manager and run exemplar programmes to improve frontline staff retention.
Verbatim wording from the response “• We appointed a People Promise Manager and started exemplar programmes to improve retention of frontline staff. Retention ensures that staff turnover is reduced, and we maintain a skilled workforce with knowledge and experience.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase paramedic apprenticeship numbers to expand the clinical workforce responding to patients.
Verbatim wording from the response “• We increased our paramedic apprenticeship numbers to increase the number of clinical staff that can respond to patients.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the joint healthcare-partner process governing ambulance handover waiting times across all SCAS-area hospitals.
Verbatim wording from the response “• The new joint process with our healthcare partners in relation to the amount of time an ambulance crew will wait at a hospital to handover their patient that was discussed at the inquest hearing has been successfully implemented with all hospitals within the SCAS geographical area. This has resulted in our Category 2 response times improving by 6 minutes to an average of 24 minutes in January and February 2025.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ambulance-crew skill mix and dispatch clinical or non-clinical resources according to patient needs.
Verbatim wording from the response “• We have reviewed the skill level of crews that are on our ambulances to ensure we have the appropriate skill mix on every resource depending on the incident they are being tasked to. We now have two types of resources, clinical and non-clinical, which are dispatched to patient’s dependent on their needs.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh dispatch models to avoid unnecessary multiple-vehicle dispatches and review continued rapid-response-vehicle deployment.
Verbatim wording from the response “• We are refreshing our dispatch models to ensure multiple vehicles are not dispatched to an incident to maintain resource availability. This refresh will include a review of the need for continued deployment of a rapid response vehicle when an ambulance arrives.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remodel Emergency Call Taker staffing to identify numbers required for reliable operational demand.
Verbatim wording from the response “Within the CCC we have undertaken the following work in addition to the work that you have already been informed of via evidence for the hearing:” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing critical call process remains in place for time-critical 999 situations.
Verbatim wording from the response “In relation to call answer time, you are already familiar with the critical call process available where a BT operative becomes aware of, or is informed of, a time critical situation from the evidence provided to you for the inquest by both SCAS and BT. I have therefore not covered this within my letter but can confirm that this process remains in place.” Source location Response from South Central Ambulance Service
Open published response
15 Dec 2022 Neal Terence Saunders · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Inconsistent terminology for the ABD umbrella term across services View source Lack of paramedic guidance on the danger of prolonged restraint View source Lack of guidance defining prolonged restraint View source Lack of checking of infrequently used guidance View source Incorrect training about ambulance response categorisation for ABD View source Failure of classroom-based ABD training to be retained and embedded View source Unclear applicability of restraint guidance to people under arrest View source Incorrect training about chemical sedation by first responding ambulance staff View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neal Terence Saunders · 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
Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology for the ABD umbrella term across services
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic guidance on the danger of prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint , and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checking of infrequently used guidance
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed . The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about ambulance response categorisation for ABD
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of classroom-based ABD training to be retained and embedded
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received . I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively .
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded ?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of restraint guidance to people under arrest
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified ).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about chemical sedation by first responding ambulance staff
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with TVP to ensure officers understand that call takers will contact them at scene to support accurate triage and ambulance-response categorisation.
Verbatim wording from the response “c. We are also working with TVP to ensure that their officers are aware that our call takers will attempt to contact them at the scene so that a more accurate triage can be undertaken. Whilst it is recognised it may not always be possible for a police officers to answer their telephone, it is important that police officers understand the process that will be followed so that the appropriate category of ambulance response can be arranged for the patient.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a directive requiring phonetic transmission and receipt of acronyms during emergency-service handovers.
Verbatim wording from the response “b. In addition we have drafted a directive regarding using the phonetic alphabet to pass over and receive information from other emergency services. As you know, in this specific case, the incorrect information was provided to the Trust by TVP which affected the category of ambulance response initially required. Going forward, whilst the full name of the medical condition will always be confirmed, any acronyms will be handed over phonetically as well as minimise the risk of information being lost in translation.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.
Verbatim wording from the response “To confirm, your Regulation 28 report was predominantly aimed at the national bodies responsible for providing training and guidance to police and ambulance service emergency personnel. Within that report, you asked the South Central Ambulance Service to consider working jointly with Thames Valley Police (TVP) to review our policies and training as suggested by our Medical Director during the evidence he provided to you.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen staff guidance on clinical responsibility, continuous restraint review, obtaining prior restraint duration, and avoiding prone positioning.
Verbatim wording from the response “In the interim, it is our intention to strengthen the direction we provide to our staff to ensure there is a clear understanding of the role they must play when attending to a patient who is subject to restraint by police officers or has been restrained prior to our attendance. The guidance will confirm that once in attendance ambulance personnel are clinically responsible for the wellbeing of the patient and they must work with police officers to ensure that any restraint is subject to continuous review and adjusted where appropriate to ensure the wellbeing of the patient whilst they are conveyed to a definitive point of care. This will include making enquiries regarding the length of time the patient has been subject to restraint prior to the arrival of the ambulance crew.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore options for an ambulance physical-restraint training package while liaising with AACE on the emerging national training standard.
Verbatim wording from the response “We are aware that nationally, there is not a definition of what would constitute prolonged restraint. Evidence was provided to you regarding this during the inquest hearing. The guidance currently provided to ambulance staff confirms that any form of patient restraint should be kept to a minimum and the form of restraint must be justifiable based on the circumstances. Currently ambulance personnel do not receive any specific training regarding physical restraint. We are aware that The Association of Ambulance Chief” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing mobile access to current JRCALC guidelines is considered sufficient because no Trust staff difficulties accessing the guidance have been identified.
Verbatim wording from the response “As you will be aware from previous correspondence and engagement with the Trust, we provide our staff access to the JRCALC guidelines via the mobile APP. This ensures that they are able to access the most up to date version of the guidance for any condition or set of circumstances they may be presented with when they are with the patient they are treating. Whilst it was apparent during the evidence you heard that the paramedic involved in this specific case, who worked for a private provider rather than the Trust, was not aware of some of the specific wording of the guidelines, he was aware that placing someone in a prone position should be avoided generally. From our review, there is no evidence that staff employed by the Trust have experienced any difficulties in accessing the guidance whether due to them being unaware of how to or because of technical difficulties in doing so.” Source location Response from South Central Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Joint face-to-face training with Thames Valley Police is not currently feasible because of operational demands, although this will be kept under review.
Verbatim wording from the response “2. Operational staff” Source location Response from South Central Ambulance Service
Open published response
5 Aug 2020 Richard KING · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to follow recognition protocols and procedures 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
Richard KING · 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
Richard King developed sudden acute back pain at home on 12 October 2019, and a paramedic attended after his son called the ambulance service. The paramedic did not carry out recognised observations, and Mr King was later found unresponsive and confirmed dead. The inquest recorded that he died from a ruptured dissecting thoraco-abdominal aortic aneurysm, and raised concern that the failure to conduct detailed observations resulted in a lost opportunity for further medical treatment and hospital assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow recognition protocols and procedures
Wider context from the report “The paramedic who attended the deceased originally did not follow recognise protocols and procedures .
” Open source report
25 Sep 2019 William James Moody · Prevention of Future Deaths report Hampshire
View report summary
Concerns raised 2 Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency View source Failure to share information between emergency agencies without repeating caller screening 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
William James Moody · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William James Moody, aged 85, intentionally entered the River Itchen from the banks of his home on 19 April 2019 and could not be revived after being taken to Southampton General Hospital. The report raises concerns that Hampshire’s 999 call-handling system may cause delays, missed triage opportunities and inadequate information-sharing between emergency services during mental health crises involving suicidal ideation.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency
Wider context from the report “At Mr Moody’s Inquest I heard that his family (who were present throughout events as his daughter and son-in-law on the Estate in which Mr and Mrs Moody had a cottage) initially called 999 and asked for the Police to attend. The 999 call-taker triaged the call as requiring the attendance of Ambulance Service and deemed this to be a matter that the Police would not attend. This resulted in the family having to redial 999 and ask for an alternative service; during which some level of screening questions were repeated. This caused delay in the family reaching an appropriate service to attend.
I heard evidence from the Mental Health Lead for Hampshire Constabulary who explained that as the incident on the 19th April 2019 was occurring in the person’s home and, as such the Police have no power to intervene where a person is in their own home and in mental health crisis and/or threatening to harm themselves. The situation on the 19th of April was distinguished from that which had happened the day before, on the 18th April, as the incident on the 18th had occurred in a public place and so, in that case, the police had a duty to attend.
I heard further evidence that there is a Memorandum of Understanding (“MOU”) between Hampshire Police and the South Central Ambulance Service as to who is the primary response agency for persons making threats of suicidal ideation.
Ultimately, the family were confused as to where help would come from and the call-handler will not transfer the call to a particular route/service unless the caller makes the decision as to which service they need. Despite there being a MOU between the agencies this does not appear to be something that the general public is aware of, and the task of making the general public aware of this is likely to be insurmountable and therefore it remains entirely foreseeable that future delays could occur because callers are unaware of which emergency service is the correct one to request in a situation where a person is suffering a mental health crisis episode and/or expressing suicidal ideation within the boundaries of their home.
I heard further evidence regarding the existence of a different triage system, that operates in at least one area/jurisdiction of the country, but this only applies when a caller dials the 111 service; callers are given an option of accessing “Mental Health” services and this allows calls to be triaged through to an appropriately trained team/call-handler who can ask a set of wider diagnostic questions to understand and establish which agency, on the particular facts, should be the primary response service to that individual.
In the situation of Mr Moody it transpired that it was actually a mixed response that was required; both the Police and Ambulance services.
I am concerned that the current system of dealing with 999 calls in Hampshire gives rise to the potential for opportunities to be missed to triage the emergency call quickly and effectively , and to share information between agencies without the need to repeat the screening approach, and these factors may result in further deaths in the future.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share information between emergency agencies without repeating caller screening
Wider context from the report “At Mr Moody’s Inquest I heard that his family (who were present throughout events as his daughter and son-in-law on the Estate in which Mr and Mrs Moody had a cottage) initially called 999 and asked for the Police to attend. The 999 call-taker triaged the call as requiring the attendance of Ambulance Service and deemed this to be a matter that the Police would not attend. This resulted in the family having to redial 999 and ask for an alternative service; during which some level of screening questions were repeated. This caused delay in the family reaching an appropriate service to attend.
I heard evidence from the Mental Health Lead for Hampshire Constabulary who explained that as the incident on the 19th April 2019 was occurring in the person’s home and, as such the Police have no power to intervene where a person is in their own home and in mental health crisis and/or threatening to harm themselves. The situation on the 19th of April was distinguished from that which had happened the day before, on the 18th April, as the incident on the 18th had occurred in a public place and so, in that case, the police had a duty to attend.
I heard further evidence that there is a Memorandum of Understanding (“MOU”) between Hampshire Police and the South Central Ambulance Service as to who is the primary response agency for persons making threats of suicidal ideation.
Ultimately, the family were confused as to where help would come from and the call-handler will not transfer the call to a particular route/service unless the caller makes the decision as to which service they need. Despite there being a MOU between the agencies this does not appear to be something that the general public is aware of, and the task of making the general public aware of this is likely to be insurmountable and therefore it remains entirely foreseeable that future delays could occur because callers are unaware of which emergency service is the correct one to request in a situation where a person is suffering a mental health crisis episode and/or expressing suicidal ideation within the boundaries of their home.
I heard further evidence regarding the existence of a different triage system, that operates in at least one area/jurisdiction of the country, but this only applies when a caller dials the 111 service; callers are given an option of accessing “Mental Health” services and this allows calls to be triaged through to an appropriately trained team/call-handler who can ask a set of wider diagnostic questions to understand and establish which agency, on the particular facts, should be the primary response service to that individual.
In the situation of Mr Moody it transpired that it was actually a mixed response that was required; both the Police and Ambulance services.
I am concerned that the current system of dealing with 999 calls in Hampshire gives rise to the potential for opportunities to be missed to triage the emergency call quickly and effectively, and to share information between agencies without the need to repeat the screening approach , and these factors may result in further deaths in the future.
” Open source report
26 Jul 2019 William VICKERS · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 4 Lack of ambulance crew access to the SCAS radio system View source Failure to ensure unobstructed ambulance access through all security gates View source Failure to include a fully qualified paramedic in the first response to prison emergencies View source Lack of staff confidence in using AEDs within the prison 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
William VICKERS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance crew access to the SCAS radio system
Wider context from the report “Firstly, I was told during the course of the evidence that the ambulance crew who attended the prison in response to the emergency call, did not have access to the radio system of SCAS . The ambulance which attended is operated by Jigsaw Medical Services which is denied access to the system . I believe this policy should be reviewed urgently and consideration given to ensure that all ambulance crews have access to the radio system.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure unobstructed ambulance access through all security gates
Wider context from the report “During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident . Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient . The present system in my view puts prisoners’ lives at risk .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include a fully qualified paramedic in the first response to prison emergencies
Wider context from the report “Secondly I am concerned that the first response did not include a “paramedic” . I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff confidence in using AEDs within the prison
Wider context from the report “During the course of the evidence I was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use.
” 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 a joint process allowing ambulance staff to retain operational radios and work mobile telephones when attending prisoners.
Verbatim wording from the response “3. Operational radios and mobile telephones” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint prison access process to provide ambulance crews with timely access to patients and identify expected emergency resources.
Verbatim wording from the response “2. Access to the prisoner (patient).” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a prison call-triage process requiring callers to provide accurate information about the patient’s condition.
Verbatim wording from the response “As part of the review we are undertaking with our local prisons, we are facilitating a fixed process regarding call triaging, access to the prison and retention of our personnel’s operational radios and mobile telephones. I will detail each point separately below.” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform private provider firms that they can pursue their own Airwave licence and radio equipment for permanent radio access.
Verbatim wording from the response “For private provider crews to have permanent access to the radio system, they must apply for a licence for their own organisation and procure the radio equipment. Following receipt of your report, we will ensure that the private provider firms that we work with are aware of this option so they can consider whether it is an option they would like to pursue.” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a specification requiring paramedic backup for immediately life-threatening incidents, including cardiac or respiratory arrest.
Verbatim wording from the response “To offer you assurance that a Paramedic will always be dispatched to attend immediately life-threatening incidents, within our standard operating procedures, there is already a specification for a paramedic crew to be sent to all patients who are in cardiac or respiratory arrest (see below).” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanent Airwave access for private providers requires them to obtain their own licence and radio equipment.
Verbatim wording from the response “The airwave radio system used by SCAS, and NHS Ambulance Trusts nationally, is governed by strict licence conditions. I have included a copy of the ‘Airwave Code of Practice – NHS Ambulance Service Profile’ with this letter. The licence terms (copied below) dictate that any private provider using the radio system must have their own licence.” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Paramedic shortages make it infeasible to guarantee that every ambulance crew includes a paramedic.
Verbatim wording from the response “As you will be aware, there are a number of different operational job roles within the prehospital environment. These include Specialist Paramedics, Paramedics, Ambulance Technicians and Emergency Care Assistants. Nationally there is a shortage of Paramedics which means that it is not feasible for us to guarantee a Paramedic is part of a crew on every resource.” Source location 2019-0255-South-Central-Ambulance-Service-NHS-Trust
Open published response
24 Dec 2018 Joyce Phoebe Mary LONG · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1 Lack of a clear, formalised understanding for obtaining nearest-hospital assistance to stabilise compromised airways 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
Joyce Phoebe Mary LONG · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joyce Phoebe Mary LONG died in hospital at 0034 hours on 11 July 2018 after striking her head at home the previous day and later collapsing. The report raised concern about differing interpretations of the reception policy at Wycombe Hospital, creating a risk that assistance to stabilise a patient's airway could be refused or delayed in similar circumstances.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear, formalised understanding for obtaining nearest-hospital assistance to stabilise compromised airways
Wider context from the report “(1) Shortly after Mrs Long had been mobilised into an ambulance outside her home address in Hazlemere, near High Wycombe, Buckinghamshire, her condition deteriorated very quickly and her Glasgow Coma Score dropped from 15/15 to 3/15. Her breathing became abnormal and irregular and she became unresponsive. Although the overall intention was to transport to John Radcliffe Hospital as a result of the traumatic head injury, the ambulance crew contacted and requested assistance from the nearest hospital, Wycombe Hospital, due to the concern over Mrs Long’s compromised airway.
Admission was refused with an instruction to attend the nearest Accident & Emergency Unit so, instead, roadside assistance was provided to the crew near Stokenchurch at the M40 junction from an Enhanced Care Response Unit whilst en route to John Radcliffe Hospital.
Due to the severity of the injury Mrs Long had sustained, exacerbated over the day prior to collapse by her warfarin prescription, the refusal of assistance by Wycombe Hospital (part of Buckinghamshire Healthcare NHS Trust) did not impact upon the outcome in this case.
There was, however, a clear difference of opinion between South Central Ambulance Service and Buckinghamshire Healthcare NHS Trust as to the interpretation of the reception policy appropriate to the Cardiac and Stroke Unit at Wycombe.
It is understood that informal discussions have been had between both trusts about whether South Central Ambulance Service should or should not be seeking assistance from Wycombe Hospital (where it is the nearest facility) in cases where a compromised airway may lead to cardiac arrest.
There is a continuing concern that, in the absence of a clear, formalised understanding, circumstances may arise where either help to stabilise a patient’s airway is refused, or a delay occurs as a result of confusion, and a patient dies as a consequence.
” Open source report
Concerns raised 12 Failure of the emergency information-relay system between birthing centres and hospitals View source Failure of midwives to acknowledge and actively consider requests for hospital transfer View source Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request View source Failure to create CTG equipment accounts for all authorised staff View source Poor technical quality of CTG readings during emergencies View source Vagueness of the Use of Standby Points policy for probing emergency requests View source Unclear classification of urgent, non-urgent and emergency transfers View source Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors View source Lack of guidance for midwives on auscultation during transfer to hospital View source Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour View source Unavailability of CTG equipment in birthing centres View source Failure to record requests for transfer to hospital in clinical notes View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rafe Robbie Angelo · 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
Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency information-relay system between birthing centres and hospitals
Wider context from the report “This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of midwives to acknowledge and actively consider requests for hospital transfer
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife . In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request
Wider context from the report “Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create CTG equipment accounts for all authorised staff
Wider context from the report “Ensuring an account is created for all staff authorised to use CTG equipment so that settings and prints can be run
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor technical quality of CTG readings during emergencies
Wider context from the report “Poor technical quality of the CTG readings at a crucial time especially given this was the first time in an emergency situation
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Vagueness of the Use of Standby Points policy for probing emergency requests
Wider context from the report “The call to SCAS from the Blake lasted 4 minutes, 57 seconds and the fact the baby was in distress was not mentioned until 3 minutes, 53 seconds. The responding ambulance was dispatched at 15:46 and shortly afterwards the paramedic contacted control centre and indicated that it was appreciated the call was an emergency but could they use the facilities first. No questions were asked and permission was given ████████ accepted that if this had been designated as a time critical call, it may have made a difference as to whether permission to use facilities would have been given and asking questions or not would depend on the person taking the call from the paramedic. There was a policy to cover this sort of request – “Use of Standby Points” but it was accepted the policy is very broad and somewhat vague so it was accepted that it would very much depend on the person taking the call to probe further
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear classification of urgent, non-urgent and emergency transfers
Wider context from the report “The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required . That is why the maternity service has purchased handsets so that the midwife giving clinical care can contact SCAS directly rather than delegate the task. The request is now made in the birthing room so the mother can hear. In evidence, ████████ indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour . This was different from ████████ who felt the transfer would be classified as non-urgent . A discussion took place in court as SCAS representatives believed the response times was 30 minutes (para 151).
This needs to be clarified between the Trust and SCAS and then clearly communicated to all staff.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors
Wider context from the report “The risk assessment of Ms Angelo followed NICE guidelines at the time but I remain concerned that no simple weigh check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs. A more holistic view is needed of risk factors especially in last few weeks from 34 weeks onwards as this is when the major growth spurt takes place and monitoring closely when additional factors surface is advisable e.g. as in this case cannabis and anti-depressant use were disclosed during this crucial period.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for midwives on auscultation during transfer to hospital
Wider context from the report “Guidance for midwives about auscultation practice during transfer to hospital
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour
Wider context from the report “After the bradycardic episode at 11:10 when the maternal position was changed, the recovery rate afterwards was higher than the previous baseline from 130-135 to 150+ thereafter. This was still within “normal” range but it was accepted during the inquest that this could be abnormal and no guidance currently exists .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CTG equipment in birthing centres
Wider context from the report “CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record requests for transfer to hospital in clinical notes
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife. In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” 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 Audit inter-hospital time-critical transfer requests and provide feedback to acute trusts and commissioners when request information conflicts with the patient’s clinical condition.
Verbatim wording from the response “To ensure that TCT requests are made by clinicians and are made in appropriate circumstances, as well as the mail drop described above, requests for inter-hospital TCT’s will now be audited by SCAS and feedback will be provided to acute Trusts and commissioners when there is a discrepancy between the information provided when the request was made and the clinical condition of the patient when SCAS arrive. This is because it is important to ensure that SCAS resources are used appropriately and are not diverted from medical emergencies in the community unnecessarily. This process will also identify at an early stage occasions where re-education or further engagement with acute Trusts is required.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the updated Standard Operating Procedure and Clinical Directive to all Emergency Operations Centre staff.
Verbatim wording from the response “The new Standard Operating Procedure and Clinical Directive has been sent to all staff in the Emergency Operations Centre. A mail drop will also be issued to all Emergency Departments and Birthing units across the South Central Area to remind all HCP’s of the correct process to request a Time critical transfer.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.
Verbatim wording from the response “The new Standard Operating Procedure and Clinical Directive has been sent to all staff in the Emergency Operations Centre. A mail drop will also be issued to all Emergency Departments and Birthing units across the South Central Area to remind all HCP’s of the correct process to request a Time critical transfer.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Emergency Operations Centre staff with guidance on diagnoses and circumstances indicating a time-critical transfer, including escalation to the Clinical Support Desk when needed.
Verbatim wording from the response “The Trust has provided the below list of diagnoses and circumstances as a guide to EOC staff. ECT’s are also instructed that if they do not understand what the medical condition is, assistance must be gained from the Clinical Support Desk.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
Verbatim wording from the response “Following your report, we have reviewed the SOP and updated it so that any Health Care Professional (HCP) requesting an Inter-facility transfer (i.e. Hospital or Birthing Unit) who asks for an emergency / immediate response will now be asked “Do you require a Time Critical Transfer?” Due to the known risks associated with obstetric emergencies. Midwives will be asked whether the case is time critical when they call from a patient’s home as well as a standalone birthing centre. If the HCP answers positively then the Emergency Call Taker (ECT) will prioritise the call using the TCT pathway and will process the call as a Category 1 response.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend and finalise the Use of Standby Points policy to clarify that crews dispatched to Time Critical or Category 1 calls cannot reasonably request facilities use.
Verbatim wording from the response “In response to this point, the Trust has reviewed the said policy and amended section 7.13 which previously read:” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to the standby-points policy require review by staff union representatives and senior operational staff before finalisation.
Verbatim wording from the response “to confirm that it will not be considered reasonable to request the use of facilities where a crew has been dispatched to a Time Critical or Category 1 call. I understand that Miss Saunders has already informed you that making changes to this policy requires a review by staff union representatives in addition to senior members of the operational team. The final review will take place on 13th February 2018 and we will of course forward a copy of the amended policy to you once it has been finalised.” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.
Verbatim wording from the response “It is not possible to provide an exhaustive list of diagnoses and circumstances that would or would not be classified as a time critical transfer due to the complex nature of medical care. However, as above, the ECT who is taking the call will now be speaking to a clinician and will ask the” Source location 2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
20 Sep 2017 Peter (Peirce) Cotter · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure of clinical decision support software to register head injuries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter (Peirce) Cotter · 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
Peter (Peirce) Cotter suffered an unwitnessed fall at home on 27 January 2017, sustaining a head injury and fractured hip, and later underwent hip surgery. The principal concern was that clinical decision support software did not appear to recognise the head injury despite his use of anticoagulant drugs.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical decision support software to register head injuries
Wider context from the report “During the course of the evidence it became apparent that Mrs Cotter had telephoned emergency services on 27th January 2017 and reported that her husband had had a fall, hit his head and hurt his hip.
My concern is that the clinical decision support software system did not appear to register that Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor head injury could have had catastrophic results if the head injury was not recognised and treated. I believe that there should be a review of the triage system to ensure that all head injuries are recognised and treated as emergencies.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot change NHS Pathways because it is designed and managed by NHS Digital.
Verbatim wording from the response “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.” Source location 2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for reviewing and changing NHS Pathways should be directed to NHS Digital.
Verbatim wording from the response “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.” Source location 2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
Open published response
11 Jul 2017 Mark William Berry · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 3 Failure to convey address information from private ambulance services to SCAS control room before staff go off duty View source Failure to include basic location details in ambulance-to-hospital handovers View source Failure to make timely and procedurally clear police notifications in appropriate deaths 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
Mark William Berry · 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
Mark William Berry suffered a cardiac arrest after apparently taking morphine or heroin and pregabalin, and was declared dead in hospital. The medical cause of death was recorded as morphine toxicity. Concerns included delays in notifying police, incomplete handover information about the address where he was found, and communication of information from a private ambulance service to the control room.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey address information from private ambulance services to SCAS control room before staff go off duty
Wider context from the report “3. Finally, the lack of an address may require further consideration of how basic but potentially important data is conveyed to SCAS control room from a private ambulance service especially before staff go off duty and thereby avoiding delay.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include basic location details in ambulance-to-hospital handovers
Wider context from the report “2. Although I was not shown the handover paperwork from the ambulance technicians to hospital staff, the lack of basic detail such as the address where Mr Berry was found may mean that handover procedures should be revisited especially if there is a private ambulance service involved.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely and procedurally clear police notifications in appropriate deaths
Wider context from the report “1. Hospital staff did not contact police in what appeared to be a suspicious and unnatural death for several hours. Further, I was told there appeared to be confusion about the correct procedure with regards to notifying police . This suggests a possible need to revisit who, when and how hospital staff contact the police both before and after death in appropriate cases.
” Open source report
Concerns raised 1 Failure to prominently highlight trial exclusions on the outside of the trial drug packet View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samantha Ann Hopkins · 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
Samantha Ann Hopkins, who was 36 weeks pregnant, collapsed at home after falling and striking her head. Paramedics initiated the PARAMEDIC 2 Trial and administered one dose of the trial drug, although pregnant women were excluded from the trial. The concern was that the exclusion warning was inside the drug packet rather than prominently displayed on its outside, and that participating ambulance services had not been given guidance on highlighting exclusions.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prominently highlight trial exclusions on the outside of the trial drug packet
Wider context from the report “Although the SCAS staff participating in the PARAMEDIC 2 Trial had been instructed as to the classes of patients to be excluded in the trial and information was provided inside the trial drug packet about the exclusions, they overlooked that pregnant women were expressly excluded and the exclusion warning inside the packet was also overlooked . If the exclusions had been prominently listed on the outside of the packet, this oversight might have been avoided. I was also told in evidence that Warwick Medical School (which is responsible for the PARAMEDIC 2 trial) had given the participating ambulance services no guidance on how the exclusions were to be highlighted to trial participants and that this had been left to the ambulance services themselves. I am concerned that exclusions should be prominently highlighted on the outside of the trial drug packet. As there are only four categories of exclusion, this should be easily achievable.
” 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 Remind staff during training and through an internal memo to check trial-drug packaging and exclusion criteria before use.
Verbatim wording from the response “Having reviewed the final label design internally, SCAS have decided to purchase bespoke plastic bags with the label agreed by University of Warwick and the Paramedic 2 team, printed on to the bag. This will ensure that the exclusion criteria are clearly visible to our staff when first selecting the trial drug pack. Staff will also be reminded during training and by an internal memo of the importance of ensuring that they are aware of the exclusion criteria and the importance of checking the packaging to remind themselves immediately before the trial drugs are used. Whilst we have assured ourselves that appropriate training on the trial is already in place, the Trust considers that this additional warning will be a vital reminder to our staff when they are presented with the time critical pressures of a cardiac arrest.” Source location 2016-0316-Response-by-South-Central-Ambulance-Services-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design an exclusion-category label for trial drug packaging.
Verbatim wording from the response “The matter was first discussed fully at the Paramedic-2 Trial Management Group (TMG) on 8th September 2016 where all five participating sites were represented. At this meeting an action plan was made to design an appropriate label detailing all of the exclusion categories’ which would be placed on further issues of the trial drug packs. Following the meeting, a label was designed for this purpose and I am pleased to enclose a copy of the final design for your information.” Source location 2016-0316-Response-by-South-Central-Ambulance-Services-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce bespoke trial-drug bags bearing the agreed exclusion-category label and affix labels to all circulating trial-drug bags.
Verbatim wording from the response “Having reviewed the final label design internally, SCAS have decided to purchase bespoke plastic bags with the label agreed by University of Warwick and the Paramedic 2 team, printed on to the bag. This will ensure that the exclusion criteria are clearly visible to our staff when first selecting the trial drug pack. Staff will also be reminded during training and by an internal memo of the importance of ensuring that they are aware of the exclusion criteria and the importance of checking the packaging to remind themselves immediately before the trial drugs are used. Whilst we have assured ourselves that appropriate training on the trial is already in place, the Trust considers that this additional warning will be a vital reminder to our staff when they are presented with the time critical pressures of a cardiac arrest.” Source location 2016-0316-Response-by-South-Central-Ambulance-Services-NHS-Trust
Open published response
Concerns raised 3 Failure to allocate appropriate priorities to ambulance calls View source Insufficient operational resilience to personnel absence or sudden sickness View source Failure to provide callers with accurate information about ambulance arrival delays View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clive GOULD · 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
Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate appropriate priorities to ambulance calls
Wider context from the report “(1) The original call made by ████████ was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions . An internal audit of that call suggests that a different priority could have been given to the original call and the presenting concerns of Mr Gould's status.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient operational resilience to personnel absence or sudden sickness
Wider context from the report “(2) In evidence before the inquest SCAS indicated that there was little resilience in the system to tolerate absence or sudden sickness of personnel at certain times .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide callers with accurate information about ambulance arrival delays
Wider context from the report “(3) The evidence from the family at the inquest was that they were informed that an ambulance would be arriving shortly . Had they known that there was to be the delays that occurred because other calls had been given priority , they informed me that they could have used first aid resources available to them within the village , such as locally trained first aiders etc.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Start ambulance crews earlier to bridge the identified morning demand gap.
Verbatim wording from the response “Rota match versus demand has also been reviewed with crews now starting duty earlier in the morning to bridge an identified gap. The forecasting demand approach has continued to be developed and is working within reasonable levels of tolerance of accuracy enabling resources to be effectively planned. We are also about to commence co-responding pilots with the Fire Service in both Oxford and Buckinghamshire which will further enhance our capacity to respond particularly in the rural areas.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend Rapid Response Vehicle cover to 24 hours across Oxfordshire, Buckinghamshire and Berkshire.
Verbatim wording from the response “SCAS response
A review has been undertaken of overnight cover and Rapid Response Vehicle cover has now been extended to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. This will provide additional resilience against short term sickness and wider geographical deployment cover in rural areas overnight.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing demand forecasting to improve resource planning.
Verbatim wording from the response “Rota match versus demand has also been reviewed with crews now starting duty earlier in the morning to bridge an identified gap. The forecasting demand approach has continued to be developed and is working within reasonable levels of tolerance of accuracy enabling resources to be effectively planned. We are also about to commence co-responding pilots with the Fire Service in both Oxford and Buckinghamshire which will further enhance our capacity to respond particularly in the rural areas.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence co-responding pilots with the Fire Service in Oxford and Buckinghamshire.
Verbatim wording from the response “Rota match versus demand has also been reviewed with crews now starting duty earlier in the morning to bridge an identified gap. The forecasting demand approach has continued to be developed and is working within reasonable levels of tolerance of accuracy enabling resources to be effectively planned. We are also about to commence co-responding pilots with the Fire Service in both Oxford and Buckinghamshire which will further enhance our capacity to respond particularly in the rural areas.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transition from AMPDS to the clinically focused NHS Pathways assessment system.
Verbatim wording from the response “SCAS have recognised that AMPDS is a dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health. The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No estimated response times are communicated because dynamic priorities may require resources to be diverted to more time-critical incidents.
Verbatim wording from the response “SCAS response
SCAS has reviewed this point and conclude that as our 999 service is a dynamic response service, situations and priorities can change and diverting of resources to a more time critical incident can happen and must take priority. Currently no ambulance service communicates at the time of a call what their response time will be for this reason. SCAS have recognised that on occasions patients may experience a delay in response due to high levels of demand. In order to support patients SCAS have developed a Clinical Support Desk (CSD) within Emergency Operations Centre who will call back and support patients with further clinical advice until a response is on scene. The CSD are very experienced nurses and can support these patients and their families.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.
Verbatim wording from the response “SCAS response
Currently SCAS operates the Department of Health licensed 999 triage software system called AMPDS. As this is a licensed tool all ambulance responses are determined at a national level. As a Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes. The AMPDS product has been developed by Priority Dispatch Corporation with a comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on a monthly basis. As we currently use AMPDS our Call Takers are required to ask a pre-determined set of verbatim questions.” Source location 2013-0357-Response-by-South-Central-Ambulance-Service
Open published response
Concerns raised 3 Delays in communication between police and the ambulance control room View source Failure to undertake continual assessment of presenting symptoms and resource deployment View source Failure to communicate whether ambulance staff should stand down or stand back View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
DAVID LESLIE SELMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause of death.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in communication between police and the ambulance control room
Wider context from the report “5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back.
5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room , this exacerbated a problem.
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake continual assessment of presenting symptoms and resource deployment
Wider context from the report “5.3 It is clearly important that a continual assessment of the patient’s presenting symptoms are related to the ambulance crew and how best to deploy resources given the circumstances of any individual case . The evidence at the Inquest was that no such assessment was undertaken .
” 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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate whether ambulance staff should stand down or stand back
Wider context from the report “5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back.
5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem.
” Open source report
Concerns raised 1 Lack of training provision for paramedics assisting births View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucy Hannah Rose Bailey · 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
Lucy was born at home following a difficult labour in which her head was delivered but her body did not initially follow. She was not breathing at birth, suffered irreparable brain damage from oxygen starvation, and died the following day. The principal concern was whether paramedic training manuals and guidelines should permit gentle traction to the baby’s head and/or gentle internal manipulation during birth.
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 South Central Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training provision for paramedics assisting births
Wider context from the report “That consideration should be given to amend the training manuals and guidelines to provide for the training of paramedics to assist a birth by providing gentle traction to the baby’s head and/or gentle internal manipulation of the baby whilst in the mothers vagina .
” 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 Update clinical practice guidance on managing shoulder dystocia during birth delivery complications, incorporating specialist obstetric and midwifery advice.
Verbatim wording from the response “I wish to inform you that a review of the UK ambulance service clinical practice guidance on the management of birth delivery complication shoulder dystocia has taken place. The guidance has been updated with advice and input from specialists in obstetrics and midwifery. We issued the updated guidance to the Medical Directors of Ambulance Trusts across the UK on 17th December 2013. We asked that the updated guidance is issued, made available to and implemented by clinical staff within their trusts.” Source location Response from South Central Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue the updated shoulder dystocia guidance to medical directors of ambulance trusts and request onward distribution, availability, and implementation by clinical staff.
Verbatim wording from the response “I wish to inform you that a review of the UK ambulance service clinical practice guidance on the management of birth delivery complication shoulder dystocia has taken place. The guidance has been updated with advice and input from specialists in obstetrics and midwifery. We issued the updated guidance to the Medical Directors of Ambulance Trusts across the UK on 17th December 2013. We asked that the updated guidance is issued, made available to and implemented by clinical staff within their trusts.” Source location Response from South Central Ambulance Service
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations