Concerns raised 9 Lack of careline policy, guidance and training for third-party emergencies View source Failure to recontact the EMA when a caller reports deterioration View source Failure to record clinically relevant information in EMA notes View source Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing View source Failure to check and improve the quality of clinical note taking View source Inadequate quality of the call auditing system View source Failure to obtain and pass on key emergency information from careline callers View source Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement View source Failure to obtain or provide basic clinical advice during careline emergency calls View source See 6 more concerns
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
Derek Thomas Burt · 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
Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of careline policy, guidance and training for third-party emergencies
Wider context from the report “2) I also heard from the careline centre manager that Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves. It was good to learn that both careline operators did respond positively to the cry for help from Mrs Burt. I remained concerned, however, that there is no policy or guidance available for operators to cover this type of emergency or life threatening situation and no training has yet been devised to learn from the unusual circumstances that occurred here .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recontact the EMA when a caller reports deterioration
Wider context from the report “In addition, the first careline operator did not call the EMA back when she learned Mr Burt was non responsive and had developed breathing problems . The CSN confirmed to me that if a second call had been made at that point then the call would have been upgraded to category 1 . This would have been at approx 22:50. In other words around the same time the EMA was trying to call Mrs Burt back. The clinical review was allocated at 22:55 and the second 999 call was logged at 23:15 so approximately 20-25 mins had elapsed.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinically relevant information in EMA notes
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review .
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing
Wider context from the report “1) I heard evidence from the call centre manager of Appello Careline and the first careline operator that their system had the capability to speak directly to Mrs Burt without her pressing her wrist alarm button as this could have been done via the digital base unit that was in her bedroom. The system can also set up a 3 way conversation or conference call to include any of the emergency services. Indeed the operator told me she has done this in the past if asked to do so by the emergency services or she has suggested it but she did not do so in this case as she took heed from the EMA.
Conversely, I heard from a CSN with South East Coast Ambulance Service (SECAMB) that she did not know careline companies could set up 3 way conference calls for a CSN to speak to the patient or helper directly. She knew that Police and Fire Services used 3 way conference calls using careline systems but not Ambulance Trusts.
This case had moved from the dispatch to the clinical stack and from the timeline of calls supplied it seems 15 calls were made between 22:52 and 23:23 to the landline and mobile numbers supplied but of course, it was impossible for Mrs Burt to answer them.
No one thought to go back through the digital base unit to offer the basic clinical advice that was needed. I am concerned that both Ambulance Trusts generally as well as Careline companies may not be aware of the potential to save lives using available technology.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check and improve the quality of clinical note taking
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others . Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of the call auditing system
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and pass on key emergency information from careline callers
Wider context from the report “3) I also remain concerned that the first careline operator did not pass on a key piece of information to the EMA, namely that the caller did not have access to a phone . Nor did she ask if the blood was spurting or dribbling . Although, it was relayed that Mrs Burt was bedbound, the EMA would not have realised that Mrs Burt couldn’t get to the phone as it was in another room.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement
Wider context from the report “6) I was told that SECAMB is taking part in a pilot called Tortoise looking at using AI to improve the accuracy of note taking. It was unclear whether a similar scheme is being explored by careline companies or if there is effective liaison between careline companies and ambulance trusts.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or provide basic clinical advice during careline emergency calls
Wider context from the report “5) I heard that an EMA can hold a call and speak to a CSN to get basic first aid advice or join the CSN into the call . Given the volume of blood that had already been lost in this case, I am concerned that this opportunity to give clinical advice was lost especially as the call had come in via a careline operator.
” 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 training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
Verbatim wording from the response “Whilst these longer-term technological developments continue to be explored, the Trust has taken immediate action by raising the learning identified through this inquest with the Training Department. A review is underway to determine what enhancements can be made to training, guidance and development processes to further support Emergency Medical Advisors in accurately documenting information obtained during emergency calls. This will be in place by the close of the financial year.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Review and strengthen access to clinical inline support by relaunching staff guidance and formalising expectations in the call-handling procedure.
Verbatim wording from the response “The Trust's operating model enables Emergency Medical Advisors (EMAs) to access real-time clinical support from clinicians, including Clinical Safety Navigators, when additional advice, guidance or decision-making support is required. This includes circumstances where calls present with complex clinical needs, unusual circumstances or communication challenges.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Amend failed-callback procedures to require Careline re-contact and consideration of three-way clinician communication when direct contact cannot be established.
Verbatim wording from the response “The Trust has reviewed the learning arising from this inquest and has amended its local operating procedure relating to failed callback processes. This guidance now specifically includes circumstances where calls originate from Careline providers.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Verbatim wording from the response “The learning arising from this case has also informed local discussions regarding the assessment of documentation quality within assurance and audit processes, with a view to ensuring that significant omissions within call records are identified, escalated and addressed through appropriate learning and improvement activity.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
Verbatim wording from the response “The Trust has also reviewed the audit findings associated with this case. During that review it was identified that documentation quality forms a relatively small component of the current NHS Pathways audit framework. SECAMB has discussed this concern with NHS Pathways, recognising the Coroner's observations regarding the significance of missing or inaccurate information within call records. As the national audit framework is owned and maintained by NHS Pathways, any review of the weighting applied to documentation standards sits within their remit. SECAMB will continue to contribute to discussions and share learning where opportunities for improvement are identified.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Review use of Careline functionality during initial 999 calls to improve communication pathways and maximise available technology.
Verbatim wording from the response “The Trust recognises the potential benefits of utilising Careline technology to support clinical assessment and the provision of appropriate advice in circumstances where conventional telephone contact is not possible. In addition to the changes already implemented within the clinical callback process, SECAMB is currently reviewing how similar functionality may be utilised by Emergency Medical Advisors at the point of the initial 999 call. This work remains ongoing and no final solution has yet been agreed;” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Develop closer partnership working with Careline providers through the Falls and Frailty Pathways of Care.
Verbatim wording from the response “As outlined elsewhere within this response, the Trust has identified opportunities to strengthen its understanding of the capabilities available through Careline providers and to improve how these capabilities can be utilised within ambulance service operations. This learning has informed broader discussions regarding collaborative working with Careline providers operating within the Trust's footprint.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 NHS Pathways owns the national audit framework, so reviewing documentation weighting is its responsibility.
Verbatim wording from the response “The Trust has also reviewed the audit findings associated with this case. During that review it was identified that documentation quality forms a relatively small component of the current NHS Pathways audit framework. SECAMB has discussed this concern with NHS Pathways, recognising the Coroner's observations regarding the significance of missing or inaccurate information within call records. As the national audit framework is owned and maintained by NHS Pathways, any review of the weighting applied to documentation standards sits within their remit. SECAMB will continue to contribute to discussions and share learning where opportunities for improvement are identified.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Current AI and automated call-handling solutions are not sufficiently developed or practicable for EMA call processes.
Verbatim wording from the response “The Trust fully recognises that accurate and comprehensive documentation is essential to support effective clinical assessment, review and decision-making throughout a patient's journey. Whilst emerging technology may offer future opportunities to improve the capture of information, SECAMB does not consider that current solutions are sufficiently developed for implementation within Emergency Medical Advisor (EMA) call handling processes at this time.” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
Concerns raised 2 Inability to provide callers with estimated ambulance attendance times View source Failure to inform callers when no ambulance is being arranged 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
Daniel Charles FORREST · 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
Daniel Charles Forrest, aged 85, suffered a witnessed fall outside his home on 30 September 2025 and later an unwitnessed fall at home on 1 October 2025. Ambulance attendance was delayed and subsequently cancelled before the second fall, after which he was taken to hospital and died from an unsurvivable head injury. The concerns were that callers were told an ambulance was being arranged and were not given reliable information about expected waiting times, potentially limiting informed decisions about waiting or escalating worsening symptoms.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to provide callers with estimated ambulance attendance times
Wider context from the report “I heard that the NHS Pathways system tells call handlers to advise callers that an ambulance is being arranged. However I heard that within SECAMB category 3 and category 4 dispositions are validated by clinical staff before being added to the Dispatch queue for an Ambulance to be allocated. I heard that this was in line with National Guidance from The Association of Ambulance Chief Executives. Therefore, callers are not informed that no ambulance is being arranged at the time of their call.
I also heard that the NHS Pathways does not allow callers to be advised of the estimated time that they may have to wait for ambulance attendance . The evidence was that SECAMB have requested that the wordings provided by NHS Pathways be altered so that there is provision to give further information to callers about how long they may wait for an ambulance to attend but this has previously been declined by NHS England.
I consider that both of the above matters mean that patients cannot make informed decisions about whether they wait for the arrival of an ambulance or escalate worsening symptoms on the basis that they anticipate that an ambulance is being arranged so will be with them shortly when this may not be 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform callers when no ambulance is being arranged
Wider context from the report “I heard that the NHS Pathways system tells call handlers to advise callers that an ambulance is being arranged . However I heard that within SECAMB category 3 and category 4 dispositions are validated by clinical staff before being added to the Dispatch queue for an Ambulance to be allocated. I heard that this was in line with National Guidance from The Association of Ambulance Chief Executives. Therefore, callers are not informed that no ambulance is being arranged at the time of their call .
I also heard that the NHS Pathways does not allow callers to be advised of the estimated time that they may have to wait for ambulance attendance. The evidence was that SECAMB have requested that the wordings provided by NHS Pathways be altered so that there is provision to give further information to callers about how long they may wait for an ambulance to attend but this has previously been declined by NHS England.
I consider that both of the above matters mean that patients cannot make informed decisions about whether they wait for the arrival of an ambulance or escalate worsening symptoms on the basis that they anticipate that an ambulance is being arranged so will be with them shortly when this may not be the case.
” Open source report
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Deliver revised scenario-based mental health learning for new operational staff and clinicians, covering pathways, collaboration, law, capacity and complex presentations.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025. View source
Action
Review emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.
Stated completedThe respondent said that this action was complete when they made their response on 13 August 2025. View source
Action
Cascade the new mental capacity protocol across all clinical teams through the Trust’s governance routes.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2025. View source
Action
Issue practice guidance for assessing capacity and escalating concerns involving suicidal patients.
Stated completedThe respondent said that this action was complete when they made their response on 13 August 2025. View source
Action
Work with partners to expand access to shared care records through the electronic Patient Care Record system.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025. View source
Action
Review and redraft the mental capacity policy, adding guidance on unsafe decisions and escalation for remote clinical advice, then issue the revised policy by Q4 2025/26.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025. View source
Action
Develop a framework for staff decision-making and documentation when suicidal patients decline conveyance, targeted for delivery by March 2026.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2025. View source
Action
Provide a half-day suicidality and mental health training session within the 2026/27 annual clinical update programme.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2025. View source
Action
Implement improved electronic documentation requirements for capacity assessments, including refusals of care, clinical justification and oversight.
Stated completedThe respondent said that this action was complete when they made their response on 13 August 2025. View source See 6 more actions
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AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” 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 Deliver revised scenario-based mental health learning for new operational staff and clinicians, covering pathways, collaboration, law, capacity and complex presentations.
Verbatim wording from the response “We have started delivering revised and improved scenario-based learning packages as part of our ‘Clinical Conversion Course’, which is for all new operational staff joining the trust, as well as our Key Skills programme for clinicians working in the Emergency Operations Centre and 111 service. The revised and improved learning packages were developed by a multi-disciplinary team of experienced mental health professionals and specifically focus on:” Source location Response from NHS South East Coast 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 emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.
Verbatim wording from the response “• To work with partners in Surrey, Kent and Sussex to further inform and develop shared decision-making pathway” Source location Response from NHS South East Coast 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 Cascade the new mental capacity protocol across all clinical teams through the Trust’s governance routes.
Verbatim wording from the response “SECAmb’s 2024/25 Quality Account reports on progress of patient safety and effectiveness of patient care. The Quality Account also outlines the Trust’s priorities for improvement for 2025/26. One of these priorities is to develop a framework for staff decision making and documentation in managing suicidal patients who decline conveyance and is expected to be delivered by March 2026. In the meantime, the new MCA protocol outlined in Section 2 above will be cascaded across all clinical teams via the Trust’s usual governance routes.” Source location Response from NHS South East Coast 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 Issue practice guidance for assessing capacity and escalating concerns involving suicidal patients.
Verbatim wording from the response “As an interim measure whilst the policy review is completed, new practice guidance ratified in August 2025 at SECAmb’s Professional Practice Group has been issued to all staff (appendix 1). This explicitly guides ambulance clinicians on how to approach mental capacity act assessments for suicidal patients, including the appropriate escalation pathways. The guidance has been designed to align with national expectations, best practice and the legal framework set out in the Mental Capacity Act (2005). The guidance is available to all our clinicians via the Trust’s intranet and clinical guidance application which can be accessed via clinicians’ mobile devices.” Source location Response from NHS South East Coast 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 partners to expand access to shared care records through the electronic Patient Care Record system.
Verbatim wording from the response “In addition to the pathway outlined above, the Trust is working closely with key partners to expand access to existing and new shared care records system platforms via our electronic Patient Care Record (ePCR) system. The expected functionality includes GP records, hospital data, community and mental health notes, with the potential for including care coordination notes, vaccination history and long-term condition (LTC) management. This will support frontline clinicians to make more informed decisions, including complex mental capacity assessments, and improve patient outcomes. Currently, only clinicians based in the Emergency Operations Centre (EOC) and Clinical Hubs have access to the Summary Care Records (SCR) and two other regional local Shared Care Records (SCRs): Kent and Medway Care Record (KMCR), Thames Valley and Surrey Care Record (TVS).” Source location Response from NHS South East Coast 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 and redraft the mental capacity policy, adding guidance on unsafe decisions and escalation for remote clinical advice, then issue the revised policy by Q4 2025/26.
Verbatim wording from the response “We are currently reviewing and redrafting our policy on mental capacity to ensure an effective and consistent approach across Surrey, Sussex and Kent. This review is scheduled to be completed with a revised policy issued by Q4 of 2025/26. The current policy doesn’t directly provide guidance on unsafe decision making that could result in significant harm or death, however this will be included in the revised” Source location Response from NHS South East Coast 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 Develop a framework for staff decision-making and documentation when suicidal patients decline conveyance, targeted for delivery by March 2026.
Verbatim wording from the response “SECAmb’s 2024/25 Quality Account reports on progress of patient safety and effectiveness of patient care. The Quality Account also outlines the Trust’s priorities for improvement for 2025/26. One of these priorities is to develop a framework for staff decision making and documentation in managing suicidal patients who decline conveyance and is expected to be delivered by March 2026. In the meantime, the new MCA protocol outlined in Section 2 above will be cascaded across all clinical teams via the Trust’s usual governance routes.” Source location Response from NHS South East Coast 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 Provide a half-day suicidality and mental health training session within the 2026/27 annual clinical update programme.
Verbatim wording from the response “We have reviewed all our learning packages related to mental health, including internal education for newly qualified paramedics. Following this review, we will be providing a half day training session on mental health as part of our annual clinical” Source location Response from NHS South East Coast 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 improved electronic documentation requirements for capacity assessments, including refusals of care, clinical justification and oversight.
Verbatim wording from the response “In Surrey, SECAmb manages approximately 230 mental health incidents a week. Responding to mental health incidents is a core component of SECAmb’s operations. Developing an improved framework for staff decision making around managing suicidal patients declining conveyance has formed part of our 2024/2025 Quality Accounts. This work has seen improvements made to our patient records system, the development of new guidance for our staff, a commitment to additional training and improvements in patient care across the SECAmb region.” Source location Response from NHS South East Coast Ambulance Service
Open published response
Concerns raised 3 Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings View source Failure to establish prison healthcare capability to replicate ambulance-service emergency skills View source Lack of cross-party dialogue and learning from serious medical emergencies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
Wider context from the report “(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primary in an acute medical emergency in a custodial setting .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish prison healthcare capability to replicate ambulance-service emergency skills
Wider context from the report “(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting . One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service ).
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-party dialogue and learning from serious medical emergencies
Wider context from the report “(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved . Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence . During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service).
” 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 Hold quarterly meetings with prison healthcare teams and governors to review incidents and escalations for learning and improvement.
Verbatim wording from the response “Regionally, the SECAmb Medway Operating Unit Leadership team meet with the prison’s healthcare team and governors every quarter and review any incidents or escalations with a view to learning and improving. Building on this, the Medway operating unit team have been invited to CPD events at the prison, and they have offered to provide restraint continuing professional development for the Trust following Azroy’s request which will be explored in relation to ongoing education and development programs for SECAmb staff. At an organisational level, a new section has been added to SECAmb’s Incident Response Plan which provides a comprehensive command-and-control framework for responding to incidents within HM Prison establishments.” Source location Response from South East Coast 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 Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.
Verbatim wording from the response “Importantly, the SECAmb Resilience Team have now completed the development of Site Specific Response Plans (SSRP) for all prison sites within our region, which has included discussion around the use of ‘Code Red and Code Blue’ terminology. These SSRPs provide a predefined attendance protocol for complex prison incidents, including the deployment of a structured command presence at the scene. They are accessible to both the Emergency Operations Centre (EOC) and frontline crews, and offer pre-agreed access, egress, and rendezvous point (RVP) information, along with site-specific risk details that must be considered to ensure a coordinated and informed response to these challenging locations. More broadly, a memorandum of understanding (MOU) is being written between SECAmb, HMP Elmley and Oxleas to articulate roles and responsibilities when attending prisons incidents.” Source location Response from South East Coast 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 Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.
Verbatim wording from the response “Regionally, the SECAmb Medway Operating Unit Leadership team meet with the prison’s healthcare team and governors every quarter and review any incidents or escalations with a view to learning and improving. Building on this, the Medway operating unit team have been invited to CPD events at the prison, and they have offered to provide restraint continuing professional development for the Trust following Azroy’s request which will be explored in relation to ongoing education and development programs for SECAmb staff. At an organisational level, a new section has been added to SECAmb’s Incident Response Plan which provides a comprehensive command-and-control framework for responding to incidents within HM Prison establishments.” Source location Response from South East Coast 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 Establish and continue the prisons task and finish group to coordinate Trust-wide prison response work and identify safety gaps and human-factors priorities.
Verbatim wording from the response “SECAmb recognises the need to ensure a coordinated approach to all the work that is happening across the Trust in relation to prisons and a task and finish group has been commissioned. An initial meeting took place on 30 July 2025. The ambition is to develop an organisation wide approach recognising appropriate place-based variation, avoid duplication and ensure any gaps are mitigated from a patient safety and care perspective. In addition, this group will seek to identify points of practice requiring further focus in terms of human factors considerations, to ensure staff of all clinical grades are confident in operating within the secure context and in conjunction with other professionals and advocating for patients’ clinical needs effectively.” Source location Response from South East Coast 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 Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.
Verbatim wording from the response “patients within secure settings like a prison is a key action for the Trust, both in terms of engaging with prison healthcare providers and ensuring that our staff understand where primacy sits.” Source location Response from South East Coast 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 Train prison nurses as ambulance-service community first responders to improve first-on-scene knowledge.
Verbatim wording from the response “To support this work and increase understanding of each other’s roles with an aim of improving integrated working, the Trust has undertaken several actions alongside the prisons within the Sheppey cluster (HMP Elmley, HMP Swaleside and HMP Stanford Hill). Specifically, SECAmb staff provided training to 7 Prison Nurses who supply a first response in the prisons in October 2024. Each participant obtained the Future Quals Level 3 Award for First Responders On scene: Ambulance Service Community First Responder qualification.” Source location Response from South East Coast 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 Primacy of care in prisons rests with commissioned prison healthcare services, while ambulance staff assume responsibility after handover and departure.
Verbatim wording from the response “For the sake of clarity, primacy of care within a prison environment rests with commissioned prison healthcare services as each prison will have its own safe systems of work and identified procedures for the provision of emergency care. Ambulance Service staff responding to emergencies within a prison will work in liaison and in conjunction with healthcare teams from that facility in line with their scope of practice and in accordance with SECAmb policies and procedures and will assume responsibility for patient care at the point of handover and departure from that facility. This is particularly important as prison healthcare staff will undertake a lead role in risk assessment processes undertaken in facilities prior to transportation.” Source location Response from South East Coast Ambulance Service
Open published response
Concerns raised 3 Unavailability of methylene blue on ambulances for relevant chemical ingestions View source Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions View source Failure to differentiate overdose call classification by clinical severity and relevant ingestion factors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joel Phillip COLK · 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
Joel Phillip Colk called 999 after ingesting at least 50g of a substance and was attended by an ambulance after the call was upgraded from category 3 to category 2. He was in cardiac arrest on attendance and died at home on 2 October 2023. The concerns include that NHS Pathways did not differentiate overdoses by substance, amount, timing or patient weight, and did not reflect the time-sensitive treatment required for this ingestion; ambulances also did not carry the antidote in the area described.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of methylene blue on ambulances for relevant chemical ingestions
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3.
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3 .
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to differentiate overdose call classification by clinical severity and relevant ingestion factors
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category . The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose . The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight . The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3.
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” 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 Apply overdose safeguards including timely clinical review, automatic escalation when delayed, TOXBASE consultation, and assessment of ongoing suicidal ideation.
Verbatim wording from the response “When an absence of immediately life-threatening symptoms such as the above is being presented in intentional overdose, the lowest ambulance disposition that can be reached is a Category 3 emergency ambulance outcome. However this Category 3 outcome is supported by additional measures specific to overdose that have been in place within SECAmb since July 2019 and further amendments to local procedures following the publication of a operational guidance by NHS England and the Association of Ambulance Chief Executives (AACE) entitled, “Category 3 – 999 Overdoses and Suicidal Ideation Calls; Initial Assessment of Lethality / Toxicity Principles Document” in April 2021, subsequently being further updated in November 2023.” Source location Response from SECAmb
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 Develop an ambulance-service workstream exploring artificial intelligence to identify rare or uniquely risky 999 calls and support earlier clinical attention.
Verbatim wording from the response “As a Trust, we would like to use this case alongside others to support a workstream in early development that we are undertaking, regarding the potential for the use of new and emerging technologies, such as Artificial Intelligence to ‘ambiently listen’ to 999 calls. The aim is to enhance patient safety and reduce human cognitive burden, potentially highlighting certain calls to clinicians that have rare or unique risks earlier. We are in the early stages of understanding this technology and undertaking this work alongside four other NHS Ambulance Trusts as part of the Southern Ambulance Collaborative, and although we envisage if successful this having wider benefits to a range of presentations that 999 ambulance calls present, we have included ████████ overdose as an example within the proposed case for change.” Source location Response from SECAmb
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 Remain engaged in national ambulance-service discussions about methylene blue for sodium nitrite poisoning and review emerging authoritative recommendations.
Verbatim wording from the response “Ongoing National Discussions” Source location Response from SECAmb
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 Continuously review the medication formulary against emerging guidance and new evidence to support patient safety.
Verbatim wording from the response “In conclusion, SECAmb remains committed to delivering the highest standard of pre-hospital care within the framework of evidence-based clinical practice. We will continuously review our medication formulary in line with emerging guidance and new evidence. At present, and in accordance with current national recommendations, equipping all front-line ambulances with methylene blue and specialist diagnostic tools is neither clinically feasible nor cost-effective. Nevertheless, we will continue to monitor evolving guidance and, where appropriate, modify our protocols to maintain patient safety and optimise outcomes.” Source location Response from SECAmb
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 Equipping all frontline ambulances with methylene blue and specialist diagnostic equipment is not clinically feasible or cost-effective because of diagnostic, logistical and resource constraints.
Verbatim wording from the response “████████ poisoning causes methaemoglobinaemia, which can only be reliably diagnosed using specialised diagnostic equipment (e.g., Masimo Rainbow SET sensors). In a pre-hospital context, the accurate identification of sodium nitrite ingestion is complicated by non-specific presentations and the unlikelihood of having immediate access to this specialist equipment on every frontline vehicle. Consequently, the administration of methylene blue in the pre-hospital setting poses significant diagnostic and logistical challenges, especially given the low incidence of confirmed sodium nitrite poisonings.” Source location Response from SECAmb
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 Existing overdose procedures provide additional clinical review, TOXBASE assessment and automatic escalation, supporting Category 3 ambulance dispositions.
Verbatim wording from the response “When an absence of immediately life-threatening symptoms such as the above is being presented in intentional overdose, the lowest ambulance disposition that can be reached is a Category 3 emergency ambulance outcome. However this Category 3 outcome is supported by additional measures specific to overdose that have been in place within SECAmb since July 2019 and further amendments to local procedures following the publication of a operational guidance by NHS England and the Association of Ambulance Chief Executives (AACE) entitled, “Category 3 – 999 Overdoses and Suicidal Ideation Calls; Initial Assessment of Lethality / Toxicity Principles Document” in April 2021, subsequently being further updated in November 2023.” Source location Response from SECAmb
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 Rapid hospital transfer and advanced cardiac life support remain the most appropriate existing response because definitive treatment is available at hospital.
Verbatim wording from the response “Although certain regions are trialling the use of Hazardous Area Response Teams (HART) to carry methylene blue, these teams are designed for high-risk environments. SECAmb’s HART operates from two bases (Ashford and Crawley), but their geographic reach and the unpredictable nature of ████████ poisonings do not guarantee they would always be the initial or timely responders to these cases. In many instances, rapid transfer to hospital—where comprehensive evaluation and definitive treatment (such as intubation, ventilation, inotropic support, or exchange transfusion) can be provided—remains the most pragmatic approach.” Source location Response from SECAmb
Open published response
24 Oct 2024 Alice Olivia CLARK · Prevention of Future Deaths report North West Kent
View report summary
Concerns raised 4 Lack of regular time-bound review of driving standards View source Lack of a formal complaint procedure for recording, investigating and communicating outcomes View source Lack of independent assessment of driving standards View source Failure to appropriately deal with complaints about unsafe driving standards View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice Olivia CLARK · 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
Alice Olivia Clark died after being trapped in a SECAMB ambulance involved in a road traffic collision on the A21 on 5 January 2022. Concerns included complaints about unsafe driving that were not appropriately dealt with, the absence of a formal complaint procedure, and the way ambulance driving standards were assessed.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular time-bound review of driving standards
Wider context from the report “(3) Driving standards are assessed by 'drive outs' with managers - should this be carried out by independent assessors and completed within a set time i.e. every 6 months or equally cctv reviewed on a regular basis of driving standards .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal complaint procedure for recording, investigating and communicating outcomes
Wider context from the report “(2) No formal complaint procedure in place . I am concerned by the evidence that a paramedic raises a complaint with their supervisor and there are no written notes/statement taken and the paramedic is not updated regarding the investigation/outcome . I am concerned that without a set complaint procedure in place with statement taking, interviews and time limits lives could be 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of independent assessment of driving standards
Wider context from the report “(3) Driving standards are assessed by 'drive outs' with managers - should this be carried out by independent assessors and completed within a set time i.e. every 6 months or equally cctv reviewed on a regular basis of driving standards.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately deal with complaints about unsafe driving standards
Wider context from the report “(1) Complaints had been received by other paramedic passengers as to the unsafe driving standards of ████████ and these were not dealt with appropriately . I am concerned that this could occur in the future and put lives at risk
” 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 Run a weekly multidisciplinary Driving Standards Review Panel to assess concerns, determine outcomes and monitor repeated concerns.
Verbatim wording from the response “In March 2023 a new weekly Driving Standards Review Panel was formed. This comprises supervisors from Operations, Risk, Security, Patient Safety, Driving Standards and Professional Standards. Any driving concern that has been raised and progressed through to Driving Standards is discussed, an outcome which can range from words of advice, through to face-to-face meeting and follow up Driver Training, to formal HR procedures; a concern could also be referred to the Police.” Source location Response from South East Coast 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 Use a documented complaint procedure requiring recorded meetings, investigation updates, outcomes and manager referral through a standard flow chart.
Verbatim wording from the response “As described above, the new Driving Standards Policy includes a documented mechanism for concerns to be raised. Driving Standards will speak to the complainant direct with appropriate support from line manager/union colleagues if they wish. Notes are now taken of meetings in response to such concerns, which form part of an investigation and presentation to the Driving Standards Review Panel. This will support other evidence such as CCTV and telematics. The complainant is now kept up to date with the investigation and will be given an outcome. A flow chart has been created by Driving Standards for Managers to follow to ensure any complaints are forwarded to Driving Standards for investigation. This flow chart will form part of the upcoming scene management training for all Operational Supervisors starting in February 2025.” Source location Response from South East Coast 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 Maintain five-yearly response-driver reassessments, annual theory training and return-to-work driving assessments before resuming full driving duties.
Verbatim wording from the response “In addition, Section 19 of the Road Traffic Act 2008 is well embedded into the Trust and has been for more than three years. This requires every response driver to be reassessed within every 5 years. In addition, there is yearly theory learning via our Key Skills course, which is mandatory training for all drivers. If any driver has been out of the Trust for any reason such as maternity or long-term sickness, they are given a driving assessment with a fully qualified Driving Instructor from the Driving Team on their return to work and they are asked to complete the online modular training before returning to full driving duties.” Source location Response from South East Coast 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 A documented driving-concerns mechanism exists, so the premise that no formal complaint procedure is in place is disputed.
Verbatim wording from the response “2. No formal complaint procedure in place. I am concerned by the evidence that a paramedic raises a complaint with their supervisor and there are no written notes/statement taken and the paramedic is not updated regarding the investigation/outcome. I am concerned that without a set complaint procedure in place with statement taking, interviews and time limits lives could be at risk.” Source location Response from South East Coast 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 Qualified assessments, five-year reassessment, annual training and incident-triggered CCTV reviews are considered sufficient instead of independent six-monthly assessments or regular CCTV review.
Verbatim wording from the response “Official driving assessments are carried out by a fully qualified driving instructor inline with Section 19 criteria and follow the standard objectives from qualifications taught by the awarding body (Futurequals). The assessments are bespoke training to the individual’s needs and are carried out by the Driver Training team only. Any reviews from the Driving Standards Review Panel are now carried out by dedicated, qualified Driving Instructor from the SECAmb Driving Team who works directly with the Review Panel to ensure any referrals are completed in a standardised and timely manner. A written report is then forwarded to the local supervisor as well as to Driving Standards. A ‘drive out’ with a local supervisor may be part of an outcome in an informal manner as a wider supporting mechanism.” Source location Response from South East Coast 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 Formal complaint response timescales are not set because they depend on the nature of the response required.
Verbatim wording from the response “Formal timescales for response are not set as these depend on the nature of the response required. However, Driving Standards will pick up an investigation as soon as it is raised and as there is a weekly meeting of the Panel the response will be timely. As soon as evidence is gained, it will be taken to the next weekly review panel and an outcome/advice forwarded that same afternoon to the relevant people.” Source location Response from South East Coast Ambulance Service
Open published response
16 Sep 2024 Philip Gordon Ross · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to complete timely clinical validation or re-triage of Category 3 and 4 calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Gordon Ross · 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
Philip Gordon Ross suffered a fall at home on 3 December 2023 and was unable to move while awaiting an ambulance. His ambulance call was not clinically validated or re-triaged promptly, and the ambulance arrived at around 02:30 hours after his condition had deteriorated. He later died in hospital on 19 December 2023 from multiple organ failure caused by rhabdomyolysis and bronchopneumonia precipitated by the fall. The principal concern was that late re-triage or clinical validation of Category 3 and 4 ambulance calls may place patients at risk of early 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete timely clinical validation or re-triage of Category 3 and 4 calls
Wider context from the report “Under the Ambulance Response Programme, Category 3 and 4 cases have response times of 120 and 180 minutes respectively. SECAMB aim to validate these calls within 90 minutes to ensure that patients receive the most appropriate care at the right time. However, SECAMB have not produced evidence that their timeline for clinical validation is being met and it was not met in this case.
Categories 3 and 4 are deemed less serious cases and therefore have extended response times for ambulance attendance, which can become further extended at times of high demand. Because of these potentially long response times, timely clinical validation is important to ensure correct categorisation and/or identify a deteriorating situation. The coroner is concerned that late re-triage or clinical validation of Category 3 and 4 calls is placing patients at risk of early death.
” 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 Recruit substantive staff, paramedics and experienced agency nurses for control-room clinical validation of 999 calls.
Verbatim wording from the response “In line with continuing high levels of anticipated demand as we approach winter an extensive recruitment campaign is under way for substantive staff, paramedics and experienced agency nurses to work in our control rooms focusing on the clinical validation of 999 calls.” Source location Response from South East Coast 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 Operate a harm review process for patients experiencing the longest daily waits for Category 3 and 4 validation, using findings to improve operational processes.
Verbatim wording from the response “We continue to operate within a challenged healthcare system with our 999 & 111 services often facing surges in activity as a barometer of pressures being experienced in the wider NHS. We recognise at times because of this we will have patients that are waiting longer for a response and have implemented a harm review process into those patients who are experiencing the longest daily waits for Category 3 & 4 validation. This information is used to identify learning and ensure our operational processes are continually reviewed and improved.” Source location Response from South East Coast 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 Roll out Urgent Care Navigation Hubs and geographically zoned clinical assessment for Category 3 and 4 patients awaiting validation.
Verbatim wording from the response “We have changed our operating model with regards Category 3 & Category 4 validation with the aim of evaluating its effectiveness over the coming months, this change of working introduced in October 2024 has seen the rollout of Urgent Care Navigation Hubs (UCNHs) based across the region, with a local focus alongside community teams from within the geography to review and undertake clinical assessments of patients awaiting a response, local oversight with “Zoning” of individual areas has given early indication of potentially identifying incidents that would benefit from earlier clinical intervention, particularly from a multi-disciplinary approach to avoid further deterioration.” Source location Response from South East Coast 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 Implement a portal enabling Urgent Community Response teams to pull suitable Category 3 and 4 patients awaiting clinical validation.
Verbatim wording from the response “Since February 2024 we have further worked collaboratively to optimise the use of Urgent Community Response (UCR) Teams across the region. UCR teams are NHS rapid response community-based teams comprising of specialist health care professionals who are able to respond to patients within 2 hours of referral and implement interventions or treatments within the patient’s home, such as managing patients who have fallen. We have implemented an innovative ‘portal’ that these teams' access and are able to ‘pull’ patients from the Category 3 & Category 4 awaiting validation queue, responding directly to a range of appropriate patients themselves who would otherwise be anticipating an ambulance service response. This has resulted in timelier clinically appropriate responses for over 1,160 patients to date who otherwise would have been waiting for clinical validation.” Source location Response from South East Coast Ambulance Service
Open published response
26 Jun 2023 Mark Steven Wright · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to respond to calls within target timeframes View source Insufficient resources to meet service demand View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Steven Wright · 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 Steven Wright deliberately overdosed on prescribed quetiapine at home during the night of 14 June or early hours of 15 June 2022, and was pronounced deceased after an ambulance arrived. The report identifies delays in the ambulance response, including SECAMBS operating under Stage 4 of its Surge Management Plan, as a significant concern because demand exceeded available resources and calls could not be answered within target timeframes.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to calls within target timeframes
Wider context from the report “There is a risk of a future recurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources to meet service demand
Wider context from the report “There is a risk of a future recurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan , meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes.
” 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 Continue working with local and national partners on programmes addressing functional demand and required clinical support.
Verbatim wording from the response “Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Adjust rota patterns to improve alignment with changed demand.
Verbatim wording from the response “challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand.” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
26 Jun 2023 Keith Nielsen · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Insufficient service resources for responding to calls within target timeframes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Nielsen · 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
Keith Nielsen fell at home, sustained a head injury while taking Warfarin, and died in hospital on 23 March 2022. The concerns included the handling of his 999 call, including the no-send disposition despite his circumstances, and repeated operation of the ambulance service at Stage 4 of its Surge Management Plan, with demand exceeding available resources and responses not meeting target timeframes.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient service resources for responding to calls within target timeframes
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 21 March 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan , meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” 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 Conduct a system-wide review with external stakeholders to develop a sustainable care delivery model for current and future public needs.
Verbatim wording from the response “Whilst SECAmb will continue to focus attention to optimise performance within the current commissioned service, it is recognised that to deliver comprehensive and sustainable improvement a full system-wide review in conjunction with external stakeholders is required, which in turn will lead to a model of care delivery that addresses the current and future requirements of the public across Kent, Surrey, Sussex, and North-East Hampshire.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Adjust rota patterns to improve alignment with changing demand.
Verbatim wording from the response “challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand.” Source location Response from South East Coast Ambulance Service NHS Foundation 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 Continue working with partners on local and national programmes addressing functional demand and clinical support.
Verbatim wording from the response “Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
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 Comprehensive and sustainable improvement requires system-wide review and solutions with external health and care stakeholders, rather than SECAmb acting alone.
Verbatim wording from the response “It is recognised that to support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across Integrated Care Systems (ICSs). With ICSs becoming legally established in July 2022, this has changed the way Health and Social Care providers work collaboratively and plan delivery of services to their populations, with an increasing focus on public health, improving performance against national and local requirements, and recognising the need for integrated strategies for key areas such as workforce (linked to the recently published NHS Long Term Workforce Plan).” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
31 Mar 2023 Veronica Jenkins · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of available staff to provide required operational hours View source Delays in hospital handovers across the region View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Veronica Jenkins · 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
Veronica Jenkins, a 72-year-old woman with metastatic bowel cancer, developed sudden chest pain on 10 May 2022 and died in hospital on 11 May 2022 after suffering two cardiac arrests. The report identified a delayed ambulance response caused by a deficit in operational hours, with concerns that staff shortages and hospital handover delays could recur and compromise patient safety.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available staff to provide required operational hours
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety. This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region. The first issue is addressed to the Chief Executive of SECAMBS and the second issue is addressed to the Secretary of State for Health and Social Care.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handovers across the region
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety. This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region . The first issue is addressed to the Chief Executive of SECAMBS and the second issue is addressed to the Secretary of State for Health and Social Care.
” 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 Continue recruiting frontline clinicians and increasing the workforce.
Verbatim wording from the response “Since May 2022 we have continued to recruit frontline clinicians and increase our workforce and work with our control room colleagues to implement call validation to ensure that where an appropriate and safe disposition can be achieved without dispatching an ambulance being required, it is done. This process increases availability of ambulances to respond to those who actually need a face-to-face assessment or urgent conveyance to a hospital.” Source location Response from South East Coast 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 commissioners and acute partners to improve hospital handover times and response times.
Verbatim wording from the response “We continue to work with commissioners and acute partners to improve hospital handover times and to ensure that the best response time possible within our funding is provided to all the patients we serve.” Source location Response from South East Coast 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 Revise operational rotas to increase staffing during periods of greatest patient demand.
Verbatim wording from the response “From April 2023 we have introduced a revision of our operational rotas with the aim of increasing the number of available staff at times of greatest patient demand (e.g. early mornings).” Source location Response from South East Coast Ambulance Service
Open published response
7 Mar 2022 Josephine Celia BARKER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 14 Early termination of 999 call triage before completion View source Failure to follow up a paramedic request for recategorisation with clinical discussion View source Failure to recognise drowsiness as a new symptom requiring re-triage View source Unavailability of clinicians for two-hour clinical review View source Failure to distinguish persistent vomiting from initial post-injury vomiting View source Absence of Clinical Safety Navigator management of Welfare Stack priority View source Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling View source Failure to obtain available healthcare professional assessment early in call handling View source Failure to contextualise questions about worsening condition across callers View source Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury View source Failure to make callbacks after dropped calls and at the two-hour mark View source Failure to keep continuous CAD records updated with changing patient information View source Lack of policy guiding diversion of an allocated ambulance en route View source NHS Pathways tool failing to support triage of fluctuating or impaired consciousness View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Josephine Celia BARKER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Early termination of 999 call triage before completion
Wider context from the report “1. The initial early exit of the first 999 call without full triage - this results in a category 3 response. There is no reason full triage could not have continued .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up a paramedic request for recategorisation with clinical discussion
Wider context from the report “12. The off-duty paramedic request re categorisation was not followed and the challenge to it did not lead to a clinical discussion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise drowsiness as a new symptom requiring re-triage
Wider context from the report “9. When Jo was reported as drowsy, this was not considered as a new symptom and she was not re-triaged .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinicians for two-hour clinical review
Wider context from the report “6. There should have been a clinical review at 2 hours . I have heard that there was not because there were not enough clinicians available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish persistent vomiting from initial post-injury vomiting
Wider context from the report “11. Jo’s vomiting was not the same symptom over time . Vomiting initially after a head injury is not the same as still vomiting after it two hours later .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of Clinical Safety Navigator management of Welfare Stack priority
Wider context from the report “4. There was no Clinical Safety Navigator in place to manage the Welfare Stack . This is an alert that gives an indication to those viewing the list of cases waiting for an ambulance of the priority of the call within its category. Jo’s case had a number of features which would have led to it becoming a priority within its category and potentially being upgraded : the incident was outside and therefore less safe and comfortable than waiting in a home/workplace; the day was very cold and there was a risk of hypothermia particularly as Jo was lightly dressed in gym clothes and lying on the asphalt of the car park floor and as time passed she had been waiting a long time and finally her case breached its time limit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling
Wider context from the report “5. At no point did a clinician have any input into the calls after the initial question from the call handler of call 1 as to whether this was major trauma or not and therefore there was no clinical assessment by SECAMBS of Jo’s condition over the following two and a half hours : she was vomiting for over two hours after the fall, she had fluctuating consciousness and was rousable to shaking and not to voice. She had had a tonic-clonic seizure and had potentially been injured by being hit by a car. She was unable to open her eyes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain available healthcare professional assessment early in call handling
Wider context from the report “3. An off-duty paramedic was on scene throughout and had clinical experience which was not asked for until the final 999 call when the call handler was passed to him by the second off-duty paramedic (from HART) who had arrived on scene and made the call. There has been no reason given as to why the off-duty paramedic’s assessment was not asked for earlier and I was told that there is a policy in place with reference to Health Care Professionals which has since been updated but does
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contextualise questions about worsening condition across callers
Wider context from the report “10. When speaking to different members of the public the questions about worsening condition were not contextualised so the caller is unable to be sure what information the call handler already has .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury
Wider context from the report “2. London Ambulance have a different major trauma protocol to SECAMBS and the fact that Jo had been potentially hit by a car – even moving slowly- and had a head injury would have been enough for the Major Trauma protocol for London Ambulance. SECAMBS major trauma protocol was not triggered because even if she had been hit by a car it was not moving fast enough to justify a major trauma category (cat 2) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make callbacks after dropped calls and at the two-hour mark
Wider context from the report “7. There were no callbacks made either to the caller whose call was dropped or to any of the callers at the 2 hour mark .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep continuous CAD records updated with changing patient information
Wider context from the report “13. The continuous CAD was not kept updated with details of Jo’s condition or other useful information when each of the calls came in.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy guiding diversion of an allocated ambulance en route
Wider context from the report “14. Call sign 239 was diverted to a welfare briefing after it had been allocated. There is no policy guiding making this decision after allocation has been made and the ambulance is en route .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
Wider context from the report “8. There is a concern over the NHS Pathways tool’s ability to deal with fluctuating consciousness . This is because there is only an assessment on conscious or on unconscious so moving between the two states triggers the call handler to move into the conscious or unconscious pathway respectively but is not able to take into account fully that consciousness level is impaired or mixed . This is considered as a huge challenge to any call handler even a clinician as it then is not established if the patient is conscious or unconscious and it forces the call handler to restart triage with each change . I was told that this can
” Open source report
4 Oct 2021 Hannah Elizabeth ROYLE · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Inadequate clinical advisor expertise and assessment of patient condition View source Insufficiently robust and discriminatory NHS abdominal pain pathway View source Failure of 111 call handlers to correctly complete the algorithm View source Misleading designation of 111 call handlers as health advisors View source Failure to provide the public with clear information about the 111 service role, capability and call-handler qualifications View source Failure to recognise complex 111 cases requiring transfer to a more senior member of the service View source Failure of the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hannah Elizabeth ROYLE · 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
Hannah Elizabeth ROYLE, a 16-year-old girl with severe learning disability, developed diarrhoea and vomiting before suffering a cardiorespiratory arrest on the way to hospital. She was diagnosed with a massive gastric volvulus and later sustained an irreversible hypoxic brain injury; she was declared brainstem dead on 1 July 2020. The report raised concerns about inadequate 111 triage, insufficient accommodation of disabilities, the clinical advisor’s assessment, public understanding of the service, misleading terminology, and the abdominal pain pathway.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical advisor expertise and assessment of patient condition
Wider context from the report “3. The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse . She was also insufficiently robust in her assessment and understanding of Hannah’s condition when the call handler contacted her for advice.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust and discriminatory NHS abdominal pain pathway
Wider context from the report “6. The NHS pathway for ‘Abdominal Pain’ is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 111 call handlers to correctly complete the algorithm
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm , they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misleading designation of 111 call handlers as health advisors
Wider context from the report “5. The 111 service is not a ‘diagnostic’ service yet the ‘call handlers’ have been renamed ‘health advisors’ . This is misleading to the public as it implies professionalism which is untrue given their underlying skills and unsubstantiated given it is their role to complete an algorithm.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the public with clear information about the 111 service role, capability and call-handler qualifications
Wider context from the report “4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service . There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed . Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise complex 111 cases requiring transfer to a more senior member of the service
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm .
” 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 Include learning-disability call handling in the next quarterly core-skills training for Health Advisors and Emergency Medical Advisors.
Verbatim wording from the response “2. Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability. A copy of the relevant part of the key skills course content is attached.” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Add complex-call handling to core mentoring competencies for new Health Advisors and Emergency Medical Advisors.
Verbatim wording from the response “3. Health Advisors and Emergency Medical Advisors have a period of mentoring following their initial training and also if any concerns are recognised during routine or requested audits. In order to pass the mentoring process, they have to demonstrate that they have passed all key competencies. This is achieved by a mentor witnessing the mentee undertake all of the required elements from within the mentoring pack to the required standard. The mentor will then sign off on the individual elements once competency is achieved. The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Issue focused complex-case learning to all 111 call-handling staff.
Verbatim wording from the response “Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken:” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Expand the Clinical Assessment Service with clinicians from a broadening range of clinical disciplines to meet diverse patient needs.
Verbatim wording from the response “In autumn 2020, SECAmb entered into a contract to provide a Clinical Assessment Service (“CAS”). The CAS is a national framework whereby 111 providers are required to employ a range of various clinical skill sets to cater for various patient needs in a virtual environment. The CAS incorporates clinicians from a very wide range of disciplines including GPs, midwives, registered Mental Health nurses, Paediatric Nurses and others; the number of clinicians and range of disciplines is increasing on a monthly basis. The objective of the CAS in the longer term is to” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Responsibility for NHS Pathways accommodating patients with underlying disabilities rests with NHS Digital.
Verbatim wording from the response “It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Responsibility for the national-policy matters concerning the 111 service’s role and Health Advisor naming rests with NHS England.
Verbatim wording from the response “4 & 5 – role and understanding of the 111 service; naming of Health Advisors” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
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 Responsibility for the NHS Pathways abdominal-pain pathway rests with NHS Digital.
Verbatim wording from the response “6 – NHS Pathway for Abdominal Pain” Source location 2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Open published response
8 Aug 2021 STEVE MARTIN BRIAN COOKE · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Failure to establish and verify the correct address during emergency call handling View source Failure to escalate when an unwell patient cannot be located View source Failure to review the original emergency call recording to establish the correct address View source Failure to conduct an adequate location-finding follow-up call View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
STEVE MARTIN BRIAN COOKE · 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
Steve Martin Brian Cooke had COVID-19 pneumonia following a COVID-19 infection and was found deceased at home on 26 December 2020. He had called an ambulance with extreme shortness of breath and apparent hypoxia, but communication difficulties led to the ambulance being sent to the wrong address and him not being located. Concerns included the failure to obtain his correct address, insufficient communication with his ex-partner, and failure to escalate the matter or review the original call when he could not be found.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and verify the correct address during emergency call handling
Wider context from the report “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located :
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment . The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke.
The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner:
(i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient
(ii) did not give a complete explanation of the reason for the call
(iii) did not ask for Mr Cooke’s current address
(iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond
(v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located
(ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived.
(iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate when an unwell patient cannot be located
Wider context from the report “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located:
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke.
The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner:
(i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient
(ii) did not give a complete explanation of the reason for the call
(iii) did not ask for Mr Cooke’s current address
(iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond
(v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located
(ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived.
(iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review the original emergency call recording to establish the correct address
Wider context from the report “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located:
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke.
The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner:
(i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient
(ii) did not give a complete explanation of the reason for the call
(iii) did not ask for Mr Cooke’s current address
(iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond
(v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located
(ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke . Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived.
(iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate location-finding follow-up call
Wider context from the report “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located:
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke.
The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner:
(i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient
(ii) did not give a complete explanation of the reason for the call
(iii) did not ask for Mr Cooke’s current address
(iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond
(v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located
(ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived.
(iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
” 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 111-service requirement for callers to provide and confirm the ambulance address through an Operational Bulletin.
Verbatim wording from the response “It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.” Source location 2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
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 a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.
Verbatim wording from the response “2. Our process upon a patient not being found by crew on scene” Source location 2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
Open published response
19 Feb 2021 Lisa CODLING · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Delays in ambulance response to acute overdose emergencies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lisa CODLING · 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
Lisa Codling, aged 49, took an overdose of paracetamol on 5 September 2020 after an emotionally charged encounter, and her death was confirmed by paramedics that evening. The principal concern was that the ambulance took 3 hours and 10 minutes to arrive; the inquest found that earlier arrival might have allowed ICU treatment that could have changed the outcome.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to acute overdose emergencies
Wider context from the report “(1) In her email of 12th October 2020 ████████ gave (in response to my question) her reply as to why South East Coast Ambulance Service would not be conducting a Serious Incident Report. The penultimate point stated “clinicians advise that paracetamol will not kill a patient within a 3 hour timeframe although a paracetamol overdose should still be considered in time sensitive emergency.” In this case of acute overdose the ambulance service took 3 hours and 10 minutes to arrive. Too late for Ms. Codling.
” 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 Meet NHS Pathways to share learning and progress concerns recorded on the Pathways issue log.
Verbatim wording from the response “We further propose to:” Source location 2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
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 Discuss the case with the NHS England and NHS Improvement national clinical lead developing an overdose triage and clinical oversight framework.
Verbatim wording from the response “Action that SECAmb has taken/proposes to take” Source location 2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
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 Refer intentional and unintentional overdose calls to a clinician before dispatching an ambulance.
Verbatim wording from the response “❖ The Trust had implemented (from 1 May 2020) a process that exceeded NHS Pathways’ current requirements by referring intentional/unintentional overdose calls to a clinician; that new process was correctly followed.
❖ The Mental Health Clinician successfully negotiated with Ms Codling, who denied taking an overdose, to have an ambulance attend; without such professional negotiation it is apparent that Ms Codling, who evidently presented as possessing Mental Capacity, would have chosen to have no response.
❖ At all stages SECAmb preferred the information from Ms Codling’s partner and acted accordingly and in her best interest.
❖ Ms Codling’s partner stated that he had seen her take ████████ paracetamol tablets. This was the baseline information which would not have been a toxic overdose based on the average size of an adult female, and this was confirmed by post mortem findings.” Source location 2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
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 Upgrading all overdoses, including paracetamol overdoses, to Category 2 is not feasible because it could adversely affect responses to confirmed life-threatening cases.
Verbatim wording from the response “After careful consideration, we do not believe that it is feasible to upgrade all overdoses, including paracetamol overdose, to a C2 disposition, as this would have a deleterious effect on responses to those patients who are confirmed as requiring this level of response through presenting with a potentially life-threatening complaints.” Source location 2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
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 Rapid fatality after paracetamol overdose is considered extremely rare, with typical fatal toxicity progressing over days to weeks rather than hours.
Verbatim wording from the response “Rapid death as a result of paracetamol ingestion is a very rare event. The members of our Serious Incident group, which includes a multi-professional team of consultant and other senior clinicians from medicine, paramedicine and nursing, had not witnessed or encountered this presentation. Our Medical Director and Assistant Medical Director, who are both experienced Consultants in Emergency Medicine, had not encountered any such cases, nor had their Consultant in Emergency Medicine colleagues. It is for this reason that it was stated in the Serious Incident group that patients do not die from paracetamol overdose within a three-hour timeframe. Clinicians’ experience of fatality following paracetamol overdose is a” Source location 2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Open published response
30 Mar 2020 KAREN JANE BINGHAM · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Insufficient understanding between police and ambulance dispatch functions of each other’s triaging, dispatching processes and response times View source Failure of police mental health training to provide information about behaviours associated with common mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KAREN JANE BINGHAM · 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
Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch processes.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding between police and ambulance dispatch functions of each other’s triaging, dispatching processes and response times
Wider context from the report “2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police mental health training to provide information about behaviours associated with common mental health conditions
Wider context from the report “1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
” 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 Review the Surge Management Plan with the three local police forces to discuss joint actions and opportunities for closer control-room collaboration.
Verbatim wording from the response “Notwithstanding the efforts we have previously made to ensure our police colleagues are aware of our processes, we have considered, in light of this case, whether we could go further. ████████ and the EOC Operating Unit Manager responsible for dispatch ████████ are in the early stages of a review of our Surge Management Plan. We consider that it would be constructive to involve all three police forces in our area as part of that review to discuss possible joint actions that could be taken when certain levels of stress on our system are reached. There are many options that we consider worth joint discussion, some of which could lead to closer working of our respective control rooms. ████████ will work with our Blue Light Collaboration Manager to liaise with our police colleagues to explore opportunities for closer collaborative working.” Source location 2020-0081-Response-from-SECAmb_Redacted
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 Create and disseminate guidance explaining the Surge Management Plan, call prioritisation, response targets, triggers and resulting actions.
Verbatim wording from the response “with whom we principally work: Surrey, Sussex and Kent. We created and disseminated a further document for our partner agencies explaining our Surge Management Plan, including information on how we triage/prioritise calls, ARP response targets, SMP triggers and our actions. We also have in place a system for notifying Police Force Control Rooms by email when we reach the levels of our Surge Management Plan whereby there is a substantial risk that we will struggle to reach our target response times.” Source location 2020-0081-Response-from-SECAmb_Redacted
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 Prepare and distribute partner-organisation guidance on ambulance call categorisations and response targets.
Verbatim wording from the response “████████ gave evidence to the inquest of the actions taken by SECamb to ensure that our police colleagues are aware of our call categorisations and response targets. At the time the Ambulance Response Programme was rolled out in SECamb (on 22 November 2017) a comprehensive document was prepared for our partner organisations and distributed to them. This includes the three police forces” Source location 2020-0081-Response-from-SECAmb_Redacted
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 Notify police force control rooms by email when Surge Management Plan thresholds indicate substantial risk of missing target response times.
Verbatim wording from the response “with whom we principally work: Surrey, Sussex and Kent. We created and disseminated a further document for our partner agencies explaining our Surge Management Plan, including information on how we triage/prioritise calls, ARP response targets, SMP triggers and our actions. We also have in place a system for notifying Police Force Control Rooms by email when we reach the levels of our Surge Management Plan whereby there is a substantial risk that we will struggle to reach our target response times.” Source location 2020-0081-Response-from-SECAmb_Redacted
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 EOC procedures and clinical oversight make staff knowledge of police dispatching processes sufficient for safe, appropriate functions.
Verbatim wording from the response “In light of the above, I consider that the knowledge of my EOC staff of police dispatching processes is sufficient at present to enable them to carry out their functions safely and appropriately.” Source location 2020-0081-Response-from-SECAmb_Redacted
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 Each police force is responsible for internally cascading the respondent’s ambulance processes and response information to relevant personnel.
Verbatim wording from the response “SECamb rely on our police partners to disseminate internally the information that we provide. It is for each force to ensure that all relevant materials are cascaded to all those who need to know of their contents.” Source location 2020-0081-Response-from-SECAmb_Redacted
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 first matter of concern concerns Surrey Police alone and is outside the respondent’s remit.
Verbatim wording from the response “I am not able to respond to the first matter of concern raised in your report as this concerns Surrey Police alone. I therefore confine my response to the second matter of concern, namely:” Source location 2020-0081-Response-from-SECAmb_Redacted
Open published response
9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Failure to obtain complete medical and medication information from relevant sources View source Early exit from NHS Pathways Module 0 for third-party calls View source Failure to transfer important and accurate medical information to telecare and emergency services View source Lack of a facility for call handlers to pass calls directly to ambulance triage staff View source Lack of automatic flagging of medical and medication-related risks View source Failure of unanswered patient call attempts to trigger clinical review of triage decisions View source Different ambulance-call handling for third-party callers View source Unavailability of responder telephone numbers within the call handling system View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Michael WELLS · 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
John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain complete medical and medication information from relevant sources
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Early exit from NHS Pathways Module 0 for third-party calls
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important and accurate medical information to telecare and emergency services
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record , which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for call handlers to pass calls directly to ambulance triage staff
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of medical and medication-related risks
Wider context from the report “(3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet.
I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of unanswered patient call attempts to trigger clinical review of triage decisions
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Different ambulance-call handling for third-party callers
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back . Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of responder telephone numbers within the call handling system
Wider context from the report “(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet).
Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not.
The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet.
” Open source report
Concerns raised 3 Pressure on staff to avoid hospital admission View source Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer View source Failure to ensure paramedics are not instructed to reduce hernias outside their training 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
Mildred CLARK · 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
Mildred CLARK died in hospital on 17 December 2017 following infection and failure of a bypass graft, haemorrhage, and inadequate blood supply to the leg. The inquest found that delay in diagnosing the infection and haematoma limited the available medical intervention. A separate concern was raised about a paramedic being instructed by telephone to attempt hernia reduction despite not being trained to do so, and about possible pressure on staff to avoid hospital admission during winter pressure.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Pressure on staff to avoid hospital admission
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure paramedics are not instructed to reduce hernias outside their training
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so . The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained .
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Open source report
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 17 Lack of call-handling provision for identifying unrecognised ED/ABD presentations View source Inconsistency between police conveyance policy and officer training View source Conveyance policy restricting timely transport of medical emergencies View source Unavailability of national guidance for out-of-hospital rapid tranquilisation View source Lack of timely escalation of serious ED/ABD safety matters to senior management View source Insufficient coverage of ED/ABD training for front-line response staff View source Contradictory ambulance call-handling instructions View source Training that conflates ED/ABD death risk with positional asphyxia View source Conveyance policy restricting timely transport of medical emergencies View source Failure of the police Mental Health Guide to separately address ED/ABD View source Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD View source Inaccurate monitoring and capture of ED/ABD incidents View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source Failure of call-handling guidance to capture patient restraint status View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Terrence Arthur Albert Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between police conveyance policy and officer training
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment.
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers , namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option , and as long as the conveyance is approved by a senior officer.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of national guidance for out-of-hospital rapid tranquilisation
Wider context from the report “I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC . In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely escalation of serious ED/ABD safety matters to senior management
Wider context from the report “I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other deaths.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Contradictory ambulance call-handling instructions
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers, namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option, and as long as the conveyance is approved by a senior officer.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Police training that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report “The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly . I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond appropriately .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate monitoring and capture of ED/ABD incidents
Wider context from the report “I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Police training that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of call-handling guidance to capture patient restraint status
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint . If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call .
” Open source report
14 Feb 2019 John SCOTT · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 6 Failure of the callback process to remain safe for lone callers who become unresponsive View source Failure to manage support arrangements safely for callers who are alone View source Failure to ask patients with abdominal pain about a pulsating mass View source Failure to establish whether an emergency caller is alone and whether another person can be spoken to View source Failure to address alternative hospital transport when ambulance arrival is expected to take two hours or more View source Failure to explain the likely ambulance timing and estimated time of arrival View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John SCOTT · 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
John SCOTT’s death was investigated and the inquest concluded that he died from natural causes. The concerns raised related to emergency call handling, including support for callers who are alone, ambulance estimated arrival times, whether lone callers could re-contact the service if they became unresponsive, and questions about symptoms that might indicate an abdominal aortic aneurysm.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the callback process to remain safe for lone callers who become unresponsive
Wider context from the report “3. With regard to Pathways I understand that they have their particular questions but how can a person who is alone when they ring the ambulance service phone the ambulance back if they become unresponsive? This is a nonsense and may well confuse the patient who is ringing.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage support arrangements safely for callers who are alone
Wider context from the report “(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked:
1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them.
2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients with abdominal pain about a pulsating mass
Wider context from the report “4. Since we were dealing at this Inquest with a case of previously undiagnosed abdominal aortic aneurysm and since this is not an unusual scenario for Pathways or South East Coast Ambulance to come across, is it not possible to ask the patient whether they can feel anything at the site of the pain e.g., a pulsating mass. This if it is felt, could be a clear diagnostic sign.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether an emergency caller is alone and whether another person can be spoken to
Wider context from the report “(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked:
1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them.
2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address alternative hospital transport when ambulance arrival is expected to take two hours or more
Wider context from the report “At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival.
If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance?
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the likely ambulance timing and estimated time of arrival
Wider context from the report “At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival.
If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance?
” 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 Continuously review waiting-stack calls and relevant incidents to identify whether patients can safely travel to hospital independently.
Verbatim wording from the response “Clinicians and the Clinical Safety Navigator constantly review calls in the waiting stack and will review incidents that may be deemed appropriate and safe for the patient to make their own way to hospital. The clinician will exclude any high risk symptoms that may put the patient at risk if they made own way, such as the patient feeling faint and can only drive themselves - this would not be appropriate as they could collapse whilst driving and cause greater harm to themselves and other members of the public.” Source location 2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
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 Pathways is responsible for setting and changing clinical triage questions, including questions addressing abdominal aortic aneurysm risk.
Verbatim wording from the response “4. All clinical questions that are asked as part of the NHS Pathways triage system are set by the NHS Pathways clinical team and as such, cannot be changed by SECAMb. We understand from ████████ of NHS Pathways that the issue of additional questions to exclude abdominal aortic aneurysm will be part of a review into severe abdominal pain which NHS Pathways already have under way.” Source location 2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
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 Pathways is responsible for amending the script to ask whether patients are alone and provide corresponding instructions.
Verbatim wording from the response “We therefore defer to NHS Pathways to make any appropriate amendment or addition to the script to enquire as to whether the patient is alone and to amend the instructions to them accordingly. We meet with NHS Pathways on a monthly basis and we have discussed this matter with them. We understand that it is under their consideration (see more in this regard at point 3 below).” Source location 2019-0051-Response-by-South-East-Coast-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 Advice to call the ambulance service if the patient becomes unresponsive is outside the service’s control because it is prescribed by NHS Pathways.
Verbatim wording from the response “3. The advice to call back to the ambulance service if the patient becomes unresponsive is part of the NHS Pathways prescribed script and as such is outside of SECAMb’s control. In relation to this issue and those above, NHS Pathways have advised us that care instructions are currently being reviewed for inclusion hopefully into Pathways version 18 which is due for release in the autumn of this year. First party instructions (instruction direct to the patient) will now be part of that review. Given the time constraints they have on releases (including testing and clinician governance prior to release), it is possible that resulting revisions will be included in version 19 rather than version 18.” Source location 2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
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 service cannot provide an ambulance arrival timeframe because multiple factors determine when a particular ambulance resource will arrive.
Verbatim wording from the response “Paragraph two - We cannot provide a timeframe as there are so many factors involved in determining when an ambulance resource will arrive with any particular patient. We do have a “surge script” which we use when calls could potentially wait longer than the specified timeframe set by the category of call (eg. category 3 – 2 hours). I attach a copy of the script.” Source location 2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
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 service cannot add contradictory instructions to its own script because it must follow NHS Pathways and this could confuse callers.
Verbatim wording from the response “1. The question of whether a patient is alone would have to form part of the script written by NHS Pathways. The direction “once this phone call is finished, don’t ring anyone else in case we need to call you back” is part of the current Pathways script. Giving the caller the opportunity to ring someone to come to them if they are alone therefore also falls within the NHS Pathways part of the script. It would follow naturally from asking the caller if they are alone. We are obliged to adhere to the Pathways script to maintain our Pathways licence. Whilst we can add our own script after the Pathways script, it would not be sensible and would lead to confusion if we were to contradict instructions we had just given as part of the Pathways script.” Source location 2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Open published response
25 Jun 2018 MARGARET STEMP · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Lack of clinical oversight of ambulance stand-down decisions View source Reliance on Police to provide necessary welfare support View source Insufficient resources for handling high call volumes View source Failure of call takers to recognise worsening condition View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MARGARET STEMP · 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
Margaret Stemp, aged 91, was found deceased on 28 December 2017 after she and her sister had fallen and remained on the floor for over seven hours before police assistance. The inquest concluded that she died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention. Concerns included insufficient ambulance resources, reliance on police for welfare support, failure to recognise worsening circumstances, and no clinical oversight of the decision to stand down the ambulance response.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical oversight of ambulance stand-down decisions
Wider context from the report “(4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on Police to provide necessary welfare support
Wider context from the report “(2) That the Police had to be used to provide the necessary welfare support to these ladies
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for handling high call volumes
Wider context from the report “(1) That there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours and what would have been considerably longer had the Police not attended.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of call takers to recognise worsening condition
Wider context from the report “(3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance.
” 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 Require ambulance stand-down decisions to undergo two-step verification by a Dispatch Team Leader or Clinical Navigator.
Verbatim wording from the response “As a result of this incident, the procedure for standing down an ambulance has now been changed. A Support Call Taker can no longer stand down an ambulance. A two-step verification process has been introduced whereby they must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Purchase approximately 100 new ambulances over three years to increase ambulance capacity.
Verbatim wording from the response “b. We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Carry out a Demand and Capacity Review with commissioners to determine required resources and how they will be provided.
Verbatim wording from the response “c. We are, together with our commissioners, carrying out a “Demand and Capacity Review”, which will enable both parties to determine:” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Provide enhanced deterioration-recognition training to new Support Call Takers during induction.
Verbatim wording from the response “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Provide enhanced training to existing Support Call Takers on recognising deterioration and responding appropriately.
Verbatim wording from the response “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Introduce an audit system for Support Call Takers’ work, including audit criteria and scoring.
Verbatim wording from the response “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Implement a Patient Welfare Procedure requiring Support Call Takers to work with Clinical Navigators to manage waiting calls clinically.
Verbatim wording from the response “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Purchase second-hand ambulances to address anticipated winter demand pressures.
Verbatim wording from the response “b. We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Implement procedures safeguarding fallen patients’ welfare while they await an ambulance.
Verbatim wording from the response “I am grateful to the Police for their assistance on this occasion, however I fully accept that the welfare of patients is SECAmb’s responsibility, not that of the Police. Since this incident, we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in a timely manner. I attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while they are awaiting an ambulance.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-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 Review the forecasting model to improve prediction of hourly resource requirements and system pressures.
Verbatim wording from the response “d. We have planned a review of our forecasting model, with the objective of better anticipating what resources will be needed for any hour of any day, making provision for system pressures.” Source location 2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Open published response
27 Feb 2018 Kevan FUNNELL · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 5 Insufficient call-taker training and confidence to involve clinicians in difficult calls View source Failure to provide an estimated arrival time and proactive safety follow-up for waiting callers View source Unavailability of responders for the designated response timeframe View source Failure to flag clinically significant updates for call upgrading View source Failure to assign and maintain ownership of ambulance calls View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevan FUNNELL · 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
Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose in this case.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient call-taker training and confidence to involve clinicians in difficult calls
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival.
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time.
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them .
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls .
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an estimated arrival time and proactive safety follow-up for waiting callers
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse , an apology was given but there was no estimated time of arrival .
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time.
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them.
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls.
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of responders for the designated response timeframe
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival.
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time .
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them.
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls.
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag clinically significant updates for call upgrading
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call . Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival.
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time.
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them.
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls.
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign and maintain ownership of ambulance calls
Wider context from the report “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell.
You will be able to see the basic facts in Part 3 of the Record of Inquest.
This was an older man with an obvious head injury lying in the public highway on a freezing cold night.
The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017).
If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight.
At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival.
Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51.
This is really a shocking performance.
Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned.
With regard to Call 2. Effectively Call 2 was also abandoned.
Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least.
I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call.
I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time.
I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them.
████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls.
During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.
” 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 Improve demand forecasting so available ambulance and crew hours more closely match service demand.
Verbatim wording from the response “In addition, the demand for our services on the night in question was greater than had been forecast. Since then, there has been much improvement in how we forecast and during 2018 the ambulance and crew hours we have available much more closely match the level of demand.” Source location Response from South East Coast 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 Implement the NHS Pathways update strengthening guidance for assessing consciousness levels in conscious patients.
Verbatim wording from the response “On 22 November 2017, we implemented a significant update to NHS Pathways. The new version includes amendments to the supporting information for conscious patients, in order to try and make it more robust and easier for call takers in situations like this one, to identify consciousness levels. If this updated version had been in use in October 2017 then Mr Funnell would have been classified as unconscious. The disposition would therefore have most likely been a Red 2 response with a target attendance time of 8 minutes. This demonstrates the evolving nature of the Pathways system.” Source location Response from South East Coast 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 Work with commissioners on a jointly commissioned demand and capacity review to align resource requirements with service demand.
Verbatim wording from the response “To summarise, it is clear that there was an error with the original classification of Mr Funnell and then a failure to upgrade his call. For this, I am sorry. Although this was human error, the recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring. We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.” Source location Response from South East Coast 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 Remind all call takers when to upgrade calls and seek senior guidance about NHS Pathways dispositions.
Verbatim wording from the response “For Mr Funnell, the call taker did not seek to upgrade the call. This was human error. The manager of the Emergency Operations Centre (EOC) has used the learning from this case to remind all call takers about the circumstances to consider when upgrading a call and the need to seek senior guidance if there is any doubt about the disposition reached through NHS Pathways.” Source location Response from South East Coast Ambulance Service
Open published response
27 Nov 2017 Barbara Joan Howard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Shortage of paramedic staff resulting in reduced ambulance availability View source Shortage of clinicians in the Emergency Operation Centre View source Failure to contact patients to ascertain call priority when response targets are missed View source Failure to audit the required number of calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barbara Joan Howard · 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
Barbara Joan Howard fell at home on 19 July 2017, experienced delays in ambulance response and backup, and was taken to hospital, where she died from injuries sustained in the fall on 20 July 2017. The concerns included ambulance and clinician staffing shortages, failure to make a priority-assessment call when the response exceeded the target time, and ambulance-call auditing below the stated target.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of paramedic staff resulting in reduced ambulance availability
Wider context from the report “(1) In evidence the Court was informed that on 19 July 2017 the Chichester and Worthing areas had 30-40 staff vacancies made up of 2 Paramedic Practitioner roles and 25 paramedic roles. This equated to being 2 ambulances and 1 car short. I was advised that the current position is that the area is now 14 paramedics short which equates to 1 ambulance per day for the area .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of clinicians in the Emergency Operation Centre
Wider context from the report “(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category. On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact patients to ascertain call priority when response targets are missed
Wider context from the report “(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category . On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the required number of calls
Wider context from the report “(3) The evidence was that SECAMB policy is that 1300 calls per month should be audited however the audit is only about 60% on target .
” 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 Provide additional staff training to support the NHS Pathways audit function.
Verbatim wording from the response “We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Change call-volume forecasting and review rotas to align clinician capacity with demand.
Verbatim wording from the response “b. A change to the way we forecast volumes of calls, together with a rota review, to try better to align clinician capacity with demand.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Introduce technology-based solutions to streamline the NHS Pathways audit process.
Verbatim wording from the response “We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Provide dedicated, time-protected staffing for NHS Pathways audits.
Verbatim wording from the response “We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Develop a new strategy to address the paramedic and crew resourcing deficit through a scheduled resourcing-team and operations-management meeting.
Verbatim wording from the response “Despite these challenges, we are taking measures to try to improve our recruitment of crew. The introduction of the Ambulance Response Programme (ARP) in November 2017 has led discussions surrounding a different skill mix requirement in our crews and this is being monitored at our workforce and business planning meetings, the first of which was in January 2018; this group will continue to meet over the next few months, using latest data to map out what our requirements are against call volume, call categorisation and vacancy rates. This is constantly evolving. We have also planned, for later this month, a meeting between our resourcing team and our Operating Unit Managers to work towards a new strategy to address our resourcing deficit.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Increase the Band 4 technician workforce to meet demand.
Verbatim wording from the response “a new measure as we had been restricting our recruitment to degree qualified paramedics. We are also increasing our Band 4/Technician workforce to meet demand.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Obtain approval for and implement a project plan introducing recruitment and retention changes for Emergency Operations Centre clinicians.
Verbatim wording from the response “To address this issue, Secamb have created a project plan to address our EOC issues, including the implementation of radical changes to the recruitment and retention of the EOC clinicians. This plan is currently with the Director of Operations for sign-off and will then be presented to the Trust’s Executive for approval, after which it will be implemented. I attach a summary of the plan. Our initiatives also include:” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Assess recruitment of IHCD-qualified paramedics as a new recruitment route.
Verbatim wording from the response “We are exploring the possibility of recruiting IHCD qualified paramedics – those who do not have a degree but qualified following an “on the job” training route. This is” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Recruit newly qualified paramedics through live advertising and a scheduled assessment day.
Verbatim wording from the response “The Chichester and Worthing area currently has 14 vacancies, of which seven will be filled by qualifying students in March/April 2018, leaving seven truly outstanding vacancies. We have a live advert for newly qualified paramedics and have an assessment day planned for 3 February 2018.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Introduce reporting and recording systems to monitor NHS Pathways audit performance.
Verbatim wording from the response “We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Recruit and train Support Call Takers to conduct welfare callbacks and escalate clinically concerning cases.
Verbatim wording from the response “a. The creation of a new role – “Support Call Taker”. This is a non-clinical role designed to alleviate the pressure on EOC clinicians. The Support Call Takers will work in the EOC carrying out welfare callbacks. This means that where we are not able to dispatch an ambulance resource within the target time, the SCT will call the patient or the caller to ensure that the patient has not got any worse and to offer advice on such matters as keeping warm, staying hydrated and taking prescribed medication. The SCT will have the power to escalate to a clinician any patient about whom there are clinical concerns. We are recruiting and training for this role now.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Introduce the Surge Management Plan with time parameters and escalation controls for demand exceeding available resources.
Verbatim wording from the response “c. A change to the way we deal with situations where actual demand for our resources on any shift exceeds forecast demand and therefore exceeds available resources. For a number of years, we have had in place a Demand Management Plan to cope with this situation. This is no longer appropriate, since the introduction of the Ambulance Response Programme (“ARP”). ARP is a national program instigated by NHS England to address the inappropriate categorisation of 999 ambulance calls and dispatch of resources to them. ARP has introduced a new set of nationally prescribed categorisations and response times. I attach a chart summarising the new system. The objective is to match the resource requirements. Secamb introduced ARP on 22 November 2017.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-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 Monitor workforce and business-planning data to determine required crew skill mix and staffing levels.
Verbatim wording from the response “Despite these challenges, we are taking measures to try to improve our recruitment of crew. The introduction of the Ambulance Response Programme (ARP) in November 2017 has led discussions surrounding a different skill mix requirement in our crews and this is being monitored at our workforce and business planning meetings, the first of which was in January 2018; this group will continue to meet over the next few months, using latest data to map out what our requirements are against call volume, call categorisation and vacancy rates. This is constantly evolving. We have also planned, for later this month, a meeting between our resourcing team and our Operating Unit Managers to work towards a new strategy to address our resourcing deficit.” Source location 2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Open published response
5 Apr 2017 Ronald William Bennett · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Lack of hospital bed availability delaying patient admission View source Failure to complete hospital handovers within the 30-minute national standard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald William Bennett · 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
Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital bed availability delaying patient admission
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds .
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete hospital handovers within the 30-minute national standard
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes . I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes . The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds.
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” 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 Introduce an Immediate Handover Policy for ambulance-to-hospital transfers.
Verbatim wording from the response “In recent years, the delays at hospitals for ambulance crews has continually increased, to the point where they are impacting on the Trust’s ability to respond to emergency calls in the community. During 2015, in response to this ever growing problem, we introduced an Immediate Handover Policy. However, due to the challenges at the Royal Sussex County Hospital this was difficult to implement. A special Handover Workshop was facilitated last year in Brighton by Professor Matthew Cooke who had previously been National Clinical Director for Emergency & Urgent Care for the NHS. This was organised by Emergency Care Improvement Programme to seek solutions as the delays at Brighton & Sussex University Hospitals NHS Trust had been rising.” Source location 2017-0097-Response-by-South-East-Coast-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 Develop and implement a joint handover standard operating procedure with BSUH, defining responsibilities and escalation processes.
Verbatim wording from the response “In March 2017, a new joint Standard Operating Procedure was developed in partnership with BSUH providing more clarity around the process and responsibilities, including how and when to escalate. Since its implementation, there has been a marked improvement in overall performance in handover delays, although it is still the case that many hours continue to be lost.” Source location 2017-0097-Response-by-South-East-Coast-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 Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.
Verbatim wording from the response “Although I cannot give you assurance that this complex and multi-factorial problem is fixed, I am confident that the matter is now being given sufficient priority by our acute, community and primary care partners. Its impact on our services is significant, and we are doing all we reasonably can to ensure improvement is sustained.” Source location 2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Open published response
16 Jun 2016 Valerie Margaret Ellis · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Lack of a policy for discharge counselling and warning cards for Apixaban View source Failure to consult clinical advisors in complex KMSS 111 cases View source Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions View source Imprecision and unresolved improvement of the NHS Pathways clinical algorithm View source Failure of IC24 case management to keep telephone referrals open until planned callbacks occur View source Poorly organised training for IC24 clinical staff in use of the computer system View source Failure to arrange a joint RCA of KMSS 111 and IC24 investigations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valerie Margaret Ellis · 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
Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.
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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for discharge counselling and warning cards for Apixaban
Wider context from the report “1) On discharge from the hospital the use of Apixaban in an elderly confused patient being cared for by a carer with hearing loss should have merited careful counselling by the clinicians and the use of a warning card.
Whilst the hospital is taking steps to assess this area, my understanding is that no policy has been adopted and I feel it should be made a matter of urgency.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult clinical advisors in complex KMSS 111 cases
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor . I am concerned about the training schedule, particularly for those with little or no background medical knowledge . Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Imprecision and unresolved improvement of the NHS Pathways clinical algorithm
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February .
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of IC24 case management to keep telephone referrals open until planned callbacks occur
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur ; no explanation could be given as to why this happened . Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poorly organised training for IC24 clinical staff in use of the computer system
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur; no explanation could be given as to why this happened. Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 East Coast Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange a joint RCA of KMSS 111 and IC24 investigations
Wider context from the report “4) The results of investigations by both KMSS 111 and IC24 should result in a joint RCA. This has not occurred as yet and no date has apparently been arranged .
” 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 Deliver core, common-learning and shadow-shift training for KMSS 111 call takers.
Verbatim wording from the response “Developments in training issued by Pathways are incorporated into KMSS 111 training packages and we can confirm the following levels of training/developments have taken place;” Source location 2016-0252-Response-by-South-East-Coast-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 Introduce supervised live support and Pathways update training within KMSS 111 training provision.
Verbatim wording from the response “Developments introduced November 2015;” Source location 2016-0252-Response-by-South-East-Coast-Ambulance-Service-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 Expand 2016 face-to-face KMSS 111 training to six hours during October or November 2016.
Verbatim wording from the response “• 3 hours face to face training thus far” Source location 2016-0252-Response-by-South-East-Coast-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 Raise and follow up concerns about anticoagulant-related NHS Pathways algorithm risks through governance channels.
Verbatim wording from the response “Indeed as you note in your report, our Senior Manager for Quality and Clinical Governance had previously raised concerns to the Pathways team regarding the algorithm and impact regarding not only Mrs Ellis’ case but anyone in a similar situation regarding anticoagulants. The principle areas of concern raised regarded the blood loss, clinical shock and anticoagulant questions.” Source location 2016-0252-Response-by-South-East-Coast-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 Deliver three hours of face-to-face KMSS 111 training introduced during 2016.
Verbatim wording from the response “Developments being or have been introduced in 2016;” Source location 2016-0252-Response-by-South-East-Coast-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 Confirm a date with IC24 to share the Trust’s Serious Incident report findings.
Verbatim wording from the response “Turning to the matter of a joint RCA, our Trust is always open to cross-NHS collaboration and review to strive to ensure safe patient care can be provided. However the regulation 28 report does not comment on what is expected to be achieved by a joint RCA and therefore it is difficult to respond. I am aware that both our Trust and IC24 have completed Serious Incident (SI) reports and are happy to share findings and if not already in place a date can be set. However our organisations are independent of each other and we do not receive communication from an out of hours provider following such a disposition being reached and a referral passed. In turn we have no further control in the matter unless we receive a further call either following up for an out of hours call or due to a change in condition. In each case KMSS 111 is able to appropriately process the call.” Source location 2016-0252-Response-by-South-East-Coast-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 Existing NHS Pathways training and call-handling arrangements are considered sufficient to provide a safe service.
Verbatim wording from the response “Firstly and with regards to the NHS Pathways training KMSS 111 deliver, this is in line with requirements set out by the Department of Health who own the system. As commented during proceedings if three answers of ‘unknown’ are provided by the caller this would flag to pass the call to a clinician in the room. This is considered the mechanism to provide a safe service, with call takers operating within the scope of the algorithm.” Source location 2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-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 Concerns about Pathways training content, algorithm design and auditing requirements should be addressed to the Department of Health, which owns the system.
Verbatim wording from the response “Any concerns regarding the content and degree of training I would consider be appropriately directed to the Department of Health as suggested during the proceedings as they own the system, training and auditing requirements.” Source location 2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-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 The Trust has no further control after an out-of-hours referral is passed between independent organisations unless another call is received.
Verbatim wording from the response “Turning to the matter of a joint RCA, our Trust is always open to cross-NHS collaboration and review to strive to ensure safe patient care can be provided. However the regulation 28 report does not comment on what is expected to be achieved by a joint RCA and therefore it is difficult to respond. I am aware that both our Trust and IC24 have completed Serious Incident (SI) reports and are happy to share findings and if not already in place a date can be set. However our organisations are independent of each other and we do not receive communication from an out of hours provider following such a disposition being reached and a referral passed. In turn we have no further control in the matter unless we receive a further call either following up for an out of hours call or due to a change in condition. In each case KMSS 111 is able to appropriately process the call.” Source location 2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations