Concerns raised 6 Insufficient clarity and usability of vascular emergencies guidance View source Lack of clinical interpretation and action guidance for aortic dissection risk scores View source Confusing classification of aortic aneurysm and dissection guidance View source Failure to recognise and urgently manage suspected aortic dissection View source Unclear interpretation of blood pressure in suspected aortic dissection View source Inadequate analysis and organisational learning from clinical incidents View source See 3 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
JOHN SOUTHAM KEEN · 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 Southam Keen, who had a known ascending aortic aneurysm, developed sudden chest pain radiating to his back and neck at home on 19 August 2023. Paramedics recorded the aneurysm incorrectly as abdominal and took him to a local acute hospital rather than directly to a specialist arterial centre; after a delay, he suffered cardiac arrest before surgery, sustained a fatal hypoxic brain injury and died on 24 August 2023. The report raises concerns about the paramedics’ assessment, SWAST NHS’s inadequate incident review, and confusing and unclear ambulance guidance on suspected aortic dissection.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and usability of vascular emergencies guidance
Wider context from the report “JRCALC
1)
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others . Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical interpretation and action guidance for aortic dissection risk scores
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk . This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusing classification of aortic aneurysm and dissection guidance
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm , which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and urgently manage suspected aortic dissection
Wider context from the report “1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS, with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.
All clinical witnesses that gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection . Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer . If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred. The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset rad iating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation .
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians, and do not take steps to try and learn from these incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear interpretation of blood pressure in suspected aortic dissection
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning , or how the issue of a patient’s blood pressure may be relevant to overall clinical risk .
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate analysis and organisational learning from clinical incidents
Wider context from the report “1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS , with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.
All clinical witnesses that gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection. Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer. If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred. The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset rad iating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation.
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians , and do not take steps to try and learn from these incidents when they occur , then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
” 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 strengthening clinical oversight and scrutiny of investigation reports.
Verbatim wording from the response “In response to the feedback received, we have undertaken a review of our processes. While this has not identified the need for immediate structural changes, we will continue to strengthen clinical oversight and scrutiny of investigation reports to minimise the risk of similar issues occurring in the future.” Source location Response from South Western 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 investigation processes to strengthen clinical oversight and scrutiny of investigation reports.
Verbatim wording from the response “In response to the feedback received, we have undertaken a review of our processes. While this has not identified the need for immediate structural changes, we will continue to strengthen clinical oversight and scrutiny of investigation reports to minimise the risk of similar issues occurring in the future.” Source location Response from South Western 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 Support development and review of JRCALC and AACE vascular-emergency guidance.
Verbatim wording from the response “The Trust recognises that vascular emergencies are complex and can be difficult for clinicians to identify accurately. This is an area in which the Trust has been actively engaged for several years. Our work has included supporting the development of JRCALC and AACE guideline reviews completed in 2025.” Source location Response from South Western 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 Continue contributing to national JRCALC guidance development through ambulance-service clinical leadership groups.
Verbatim wording from the response “The Trust maintains strong relationships with AACE and continues to contribute regularly to the development of JRCALC guidance through the National Ambulance Service Medical Directors Group and the National Lead Paramedic Group.” Source location Response from South Western 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 national vascular guideline with AACE against the inquest findings and engage in developing clearer guidance language.
Verbatim wording from the response “In response to the inquest, a senior member of the Trust met with the Clinical Support Managers for AACE on 17 June 2026 to review the national vascular guideline against findings.” Source location Response from South Western 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 improved remote clinician support through a single telephone access point to senior clinical advice.
Verbatim wording from the response “This information is not included in national JRCALC guidance, as it is region-specific. It is acknowledged that any guideline covering the recognition of aneurysms faces the inherent challenge posed by both atypical and overlapping symptoms. In such situations, ambulance clinicians rely on their professional judgement to determine the most appropriate clinical pathway. The Trust introduced improved remote clinician support for” Source location Response from South Western 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 JRCALC is responsible for updating the national vascular guidance in line with the recommendations.
Verbatim wording from the response “During this discussion, AACE identified potential improvements to the language used within the clinical guidance to enhance clarity, particularly around the use of the acronym ‘AAA’. We are also aware that JRCALC are updating the Vascular guidance in line with the recommendations. The Trust is supportive of these proposed changes and will continue to engage proactively in their development.” Source location Response from South Western 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 process review identified no need for immediate structural changes to investigation processes.
Verbatim wording from the response “In response to the feedback received, we have undertaken a review of our processes. While this has not identified the need for immediate structural changes, we will continue to strengthen clinical oversight and scrutiny of investigation reports to minimise the risk of similar issues occurring in the future.” Source location Response from South Western Ambulance Service NHS Trust
Open published response
Concerns raised 7 Failure to assess need for hospital conveyance during nurse clinician review View source Failure to establish ambulance staff role and assessment status View source Failure to undertake sufficiently broad triage investigation View source Failure to include available family members in clerking patients with dementia View source Failure to confirm ambulance staff clinical grade during introductions View source Failure to ensure reliable sharing of ambulance clinical information between organisations View source Failure to conduct an independent physical assessment View source See 4 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
Brian Ingram · 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
Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess need for hospital conveyance during nurse clinician review
Wider context from the report “5) The nurse clinician was asked to review the x-ray only . There did not appear to have been any check as to whether Brian needed to be conveyed to RCHT which may have been appropriate if the complaint of groin pain had been noted.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish ambulance staff role and assessment status
Wider context from the report “6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake sufficiently broad triage investigation
Wider context from the report “4) Brian was seen by a triage nurse who ordered a knee x-ray only .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include available family members in clerking patients with dementia
Wider context from the report “2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm ambulance staff clinical grade during introductions
Wider context from the report “1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reliable sharing of ambulance clinical information between organisations
Wider context from the report “3) The inquest was told that it will ordinarily be a SWAST ambulance that attends the MIU and there is a process whereby an ACRF can be sent electronically with the relevant past medical history. On this occasion, an LML ambulance attended whose staff work from written Patient Clinical Records. There was a conflict in the evidence as to whether a PCR was provided to MIU staff . One had to be subsequently requested by CPFT to review what had happened on the day . It may be appropriate to review how information is shared between different organisations .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an independent physical assessment
Wider context from the report “7) The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints.
” Open source report
Concerns raised 6 Failure to call an ambulance promptly following a concern for welfare call View source Failure to verify police supervision status when determining ambulance disposition View source Failure to obtain and share complete contact information for ambulance disposition decisions View source Failure to provide police with ambulance arrival estimates and likely delay information View source Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability View source Delays in ambulance attendance 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
Lachlan Charles Campbell · 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
Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to call an ambulance promptly following a concern for welfare call
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours .
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify police supervision status when determining ambulance disposition
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached .
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and share complete contact information for ambulance disposition decisions
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police with ambulance arrival estimates and likely delay information
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options .
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “1) Delays in ambulance attendance . I have written to the Secretary of State separately in this regard and you do not need to address this in your reply.
” 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 Use dynamic internal mutual aid, including private ambulance provider resources, to support areas under greatest pressure.
Verbatim wording from the response “• Dynamic internal Mutual aid is utilised where possible (utilising Private Ambulance Provider resources on duty) to support areas of the Trust under most pressure. In effect this means moving some resources from one area to another to support response to patients in the pressurised area.” Source location Response from South Western 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 a system to provide callers with more accurate estimated waiting times by area and call category.
Verbatim wording from the response “Due to the dynamic and constantly changing nature of call triage and ambulance service resource allocation it is not currently possible to provide any caller, including police officers, with an accurate ETA for responding resources. However, SWAST is investigating the potential to create a more accurate system and to this end has commissioned a new report from the Data Analytics and Information Team for “longest current waiting call in defined area by category” (or similar) with the intention that this information can lead to the development of a system that will be able to provide a longest estimated wait time for the area in which a call originated. Whilst this will have its limitations it will be more accurate than a snapshot ETA and provide the caller with an idea of demand in the area which they can factor into any decision making as to whether to convey the patient themselves.” Source location Response from South Western 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 Train SWAST control-room staff to obtain accurate contact and incident information during calls with police.
Verbatim wording from the response “Both the police and SWAST control room staff are trained to ensure that they have asked for and received accurate information in the course of any calls held with one another. In the future this will ensure that that SWAST have a contact number for the scene of the incident.” Source location Response from South Western 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 Collaborate with hospitals, NHS England and system partners to reduce ambulance handover and wider system delays.
Verbatim wording from the response “SWAST is working in collaboration with NHS England and system partners to improve system delays.” Source location Response from South Western 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 Operate and update the handover Standard Operating Procedure, including escalation levels, locally agreed triggers and immediate handover arrangements.
Verbatim wording from the response “To assist with handover delays, a handover Standard Operating Procedure (SOP) was developed during November 2021 and introduced in late 2021. This has been reviewed and updated, including review against the agreed standards being undertaken with the acute Trust (RCHT) during December 2023/January 2024. The SOP supports robust management of delays, using four handover escalation levels. Local teams have worked with each hospital to agree the actions that they will take place at each level. The triggers for escalation have also been locally agreed, to allow a more responsive, tailored approach. The new approach includes an agreed area to implement an immediate handover for a patient where the Trust is unable to respond to an outstanding local Category 1 call within a reasonable timeframe.” Source location Response from South Western 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 Provide Hospital Ambulance Liaison Officer cover at Royal Cornwall Hospital and University Hospital Plymouth emergency departments.
Verbatim wording from the response “• Providing Hospital Ambulance Liaison Officer (HALO) cover in both the Royal Cornwall Hospital Trust and University Hospital Plymouth Trust Emergency Departments to support patient safety and crew welfare, promoting handover expedition and availability of crews to respond to patients within the community.” Source location Response from South Western 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 Use the Operations Delivery Centre to minimise resource unavailability and increase resources available for patient responses.
Verbatim wording from the response “• The Trust’s Operations Delivery Centre minimise unavailability of resources, as much as possible, to increase the resources available to respond to patients.” Source location Response from South Western 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 Whether police should convey patients to hospital is a matter for Devon and Cornwall Police to consider.
Verbatim wording from the response “In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.” Source location Response from South Western 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 Accurate ETAs cannot currently be provided because call triage and ambulance resource allocation are dynamic and constantly changing.
Verbatim wording from the response “Due to the dynamic and constantly changing nature of call triage and ambulance service resource allocation it is not currently possible to provide any caller, including police officers, with an accurate ETA for responding resources. However, SWAST is investigating the potential to create a more accurate system and to this end has commissioned a new report from the Data Analytics and Information Team for “longest current waiting call in defined area by category” (or similar) with the intention that this information can lead to the development of a system that will be able to provide a longest estimated wait time for the area in which a call originated. Whilst this will have its limitations it will be more accurate than a snapshot ETA and provide the caller with an idea of demand in the area which they can factor into any decision making as to whether to convey the patient themselves.” Source location Response from South Western Ambulance Service NHS Foundation Trust
Open published response
30 Jan 2025 Graham Whiteley · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 2 Delays in allocating ambulances View source Delays in handing over ambulance patients to acute hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Graham Whiteley · 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
Graham Whiteley, who had Alzheimer’s disease, a history of seizures and falls, and lived in a care home, walked out when doors were left unlocked and was found having fallen by the roadside with head injuries. He was conveyed to hospital by police after a substantial ambulance delay, developed pneumonia, and died in hospital on 18 June 2024. The principal concerns were delays in ambulance allocation linked to handover delays at acute hospitals, with the report stating that these delays were continuing.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in allocating ambulances
Wider context from the report “c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary).
d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers. This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays.
e) An ambulance was allocated to Mr Whitely at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr Whiteley’s ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call.
f) In the event, Avon and Somerset Police conveyed Mr Whiteley to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down.
g) The evidence given by the ambulance Trust at the inquest was that the delays in allocating ambulances caused by the delays in handing over to acute hospitals is continuing .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in handing over ambulance patients to acute hospitals
Wider context from the report “c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary).
d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers . This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays.
e) An ambulance was allocated to Mr Whitely at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr Whiteley’s ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call.
f) In the event, Avon and Somerset Police conveyed Mr Whiteley to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down.
g) The evidence given by the ambulance Trust at the inquest was that the delays in allocating ambulances caused by the delays in handing over to acute hospitals is continuing .
” 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 Hospital Ambulance Liaison Officer support at acute hospitals when required to improve patient flow.
Verbatim wording from the response “Building on the aforementioned efforts, several initiatives are being implemented locally and across the South West by SWAST. These include:” Source location Response from South Western 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 Collaborate with hospitals and system partners through operational meetings, regional task groups and senior county-level meetings to reduce handover delays.
Verbatim wording from the response “SWAST remains committed to collaborating with hospitals to address this issue. In many instances, local operations teams hold daily meetings with their respective Emergency Departments. Resolving delays has been identified as a key priority by the regional NHS England (NHSE) team, and SWAST actively participated in the NHSE Ambulance Handovers task and finish group during the summer of 2024. Additionally, in 2024, a new tier of senior county-level meetings was established, bringing together hospitals, commissioners, NHSE, and SWAST. These meetings have provided SWAST with valuable opportunities to engage in Integrated Care System (ICS) discussions aimed at reducing delays.” Source location Response from South Western 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 Implement the Somerset Timely Handover Process to initiate rapid handover when transfer has not occurred within 90 minutes of arrival.
Verbatim wording from the response “We have also collaborated with the Somerset system to implement the ‘Timely Handover Process,’ designed to initiate a rapid handover if it has not been completed within 90 minutes of arrival. This process was introduced in the area in November 2024 and following a challenging Christmas period we are now seeing early improvements in handover efficiency.” Source location Response from South Western 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 Implement and update the handover-delay standard operating procedure, including escalation levels, locally agreed triggers and immediate handover arrangements.
Verbatim wording from the response “To address handover delays, a Standard Operating Procedure (SOP) was introduced in late 2021. This has since been reviewed and updated, with a reassessment against locally agreed standards conducted in December 2023 and January 2024. The SOP facilitates the effective management of delays by employing four handover escalation levels. Local teams have collaborated with each hospital to determine the specific actions to be taken at each level. The triggers for escalation have also been locally established, enabling a more responsive and tailored approach. Additionally, the approach includes a designated area for immediate patient handover in situations where the Trust is unable to respond to a pending local Category 1 call within a reasonable timeframe.” Source location Response from South Western 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 Use mutual aid, including private ambulance providers, to strengthen system support during periods of high demand.
Verbatim wording from the response “Building on the aforementioned efforts, several initiatives are being implemented locally and across the South West by SWAST. These include:” Source location Response from South Western 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 Use the Operations Delivery Cell to minimise resource unavailability and increase response capacity.
Verbatim wording from the response “Building on the aforementioned efforts, several initiatives are being implemented locally and across the South West by SWAST. These include:” Source location Response from South Western 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 Handover delays cannot be resolved by SWAST alone and require action by hospitals and wider system partners.
Verbatim wording from the response “Handover delays at hospital trusts have the biggest impact on SWAST’s ability to respond to patients. This articulated on the SWAST corporate risk register, where a risk related to system activity and flow sits at the highest level, with a risk score of 25. The challenge with impacts of handover delays is that SWAST alone cannot solve it. In August 2023, the Health Services Safety Investigation Body (HSSIB) published a final report ‘Harm caused by delays in transferring patients to the right place of care’. This report strengthens the findings of the SWAST system PSII report that was produced in July 2022, with a review and addendum added in December 2023. It is recognised that a patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment.” Source location Response from South Western Ambulance Service NHS Foundation Trust
Open published response
15 Mar 2024 Romeo Miles Esposito · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of warning or training for clinical staff on interpreting respiratory effort View source Failure to undertake further clinical assessment of respiratory effort View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Romeo Miles Esposito · 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
Romeo Miles Esposito was found unconscious at home, where emergency staff stopped resuscitation and assessed him as dead, although he continued to make respiratory effort and his heartbeat returned before resuscitation resumed. He later died in hospital from a brain injury consequent upon his cardiac arrest; concerns included the failure to recognise the respiratory effort as requiring further assessment and the absence of evidence that staff had been warned or trained against dismissing it as “a release of air”.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of warning or training for clinical staff on interpreting respiratory effort
Wider context from the report “(1) Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours;
(2) His family raised their concerns regarding this with SWAS clinical staff on a number of occasions thoughout this period;
(3) Staff repeatedly ascribed the respiratory effort to “a release of air”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment;
(4) There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake further clinical assessment of respiratory effort
Wider context from the report “(1) Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours;
(2) His family raised their concerns regarding this with SWAS clinical staff on a number of occasions thoughout this period;
(3) Staff repeatedly ascribed the respiratory effort to “a release of air”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment ;
(4) There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment .
” 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 mandatory ALS training with cardiac-arrest simulation and discussion-based learning on post-death clinical changes, escalation and senior review.
Verbatim wording from the response “As part of the mandatory training delivered to all Trust staff for 2024 to 2025, a session on advanced life support (ALS) is to be provided. This includes a simulation around cardiac arrest management in conjunction with discussion-based learning around actions that may be required following COD. This includes the potential for a change in clinical presentation with an emphasis on this being escalated for senior review. In this scenario, the guidance dictates that in these circumstances the lead clinician must observe and reassess the patient to satisfy themselves that COD is appropriate. If any uncertainty remains, the Resuscitation Advice Line can be contacted. The Major Trauma and Resuscitation Advice Line is staffed by experienced Specialist Critical Care Practitioners supported by a duty Consultant. The team are available to offer advice to ambulance crews 24/7.” Source location Response from South Western Ambulance Service
Open published response
27 Oct 2023 Gerald Roy Cruse · Prevention of Future Deaths report Avon
View report summary
Concerns raised 7 Insufficient specialist medical capacity for timely and proactive care of older hospital patients View source Inadequate ambulance staff training in recognising and dealing with patients who have fallen View source Failure of ambulance staff to recognise falls risk and initiate further action View source Failure to identify and apply learning from falls-related incidents View source Failure to complete falls risk assessments in accordance with JRCALC guidelines View source Lack of clear guidelines for holistic management of older hospital patients View source Hospital falls causing fatal injuries View source See 4 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
Gerald Roy Cruse · 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
Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report “(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate ambulance staff training in recognising and dealing with patients who have fallen
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance staff to recognise falls risk and initiate further action
Wider context from the report “(5) The other two ambulance staff did not seem to understand that Mr Cruse was a falls risk , they did not consider that he was at a greater risk of falls and did not consider that any further action should have been considered or taken .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and apply learning from falls-related incidents
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future . Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments in accordance with JRCALC guidelines
Wider context from the report “(4) The paramedic working within the cohort area did not complete a falls risk assessment in accordance with the JRCALC guidelines following the admission of a patient who had just had a fall at home.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidelines for holistic management of older hospital patients
Wider context from the report “(2) There are currently no clear guidelines as to how these patients should best be managed and there remains a serious risk that the care they receive is not holistic .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Hospital falls causing fatal injuries
Wider context from the report “(3) Patients falling in hospitals and sustaining injuries which lead to their death remains a matter of grave concern.
” Open source report
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 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
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” 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 effective aide-mémoires for control-room dispatchers and commanders supporting joint working with HM Coastguard.
Verbatim wording from the response “We are also ensuring effective aide memoirs are in place for our dispatchers and commanders within our control room to support effective joint working with the HM Coastguard. This work has begun over the last few months and will be finalised during the forthcoming couple of months. The aim is to ensure that business-as-usual working between SWASFT and HM Coastguard is well embedded with key relationships formed, making sure that when the larger incidents happen we already have a strong working relationship.” Source location Response from South Western 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 Maintain a trained NILO cohort with two officers available around the clock to support incident commanders and partner agencies.
Verbatim wording from the response “The Trust has a cohort of NILOs, who are trained to advise and support Incident Commanders, Police, Fire, military and other Government agencies on SWASFT’s operational capacity and capability to reduce risk and safely resolve incidents at which a SWASFT attendance may be required, including major incidents, complex or protracted multi-agency incidents. The Trust has two individuals on call 24/7 who can advise and deploy to support the response to incidents to ensure effective multiagency communication.” Source location Response from South Western 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 Strengthen SWASFT–HM Coastguard coordination through commander visits and control-room shadowing.
Verbatim wording from the response “Invitations to attend JESIP courses are extended to colleagues from HM Coastguard. In addition, SWASFT is currently strengthening relationships by participating in a programme of visits by SWASFT and HM Coastguard commanders and other key role holders to other control rooms. This aims to further promoting shared understanding between SWASFT and HM Coastguard commanders of how each emergency service co-ordinates its response to incidents, and the terminology used by each service. During such a visit the visiting commander shadows the resident control commander, observing processes in operation and listening to communications with officers on-scene.” Source location Response from South Western 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 Maintain a standard operating procedure for notifying other emergency services and relevant utility providers about incidents.
Verbatim wording from the response “A standard operating procedure is in place to guide the Emergency Medical Dispatchers in our Emergency Operations Centres (the EOCs – our control rooms in Bristol and Exeter) regarding receiving emergency calls from other emergency services, and when to notify the police, fire service, coastguard or utility providers of an incident to which an ambulance has been called. Outgoing calls to other services are made to dedicated blue light service lines into their control rooms in most cases.” Source location Response from South Western 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 Provide inter-control hailing and multiagency talkgroups enabling direct ambulance, police and fire control-room communication during major or significant incidents.
Verbatim wording from the response “In the event of a Major or Significant Incident (Standby or Declared), each of SWASFT’s two EOCs can also notify, or be notified by, the police or fire services via an Inter Control Hailing Talkgroup. Following the initial notification, communications will be transferred to a specific multiagency talk group which will allow the three services to directly communicate regarding that incident through control rooms (while leaving the inter-control talkgroup free for any other notifications). This has been in place since late 2020.” Source location Response from South Western 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 Implement JESIP joint-working principles through commander, staff and control-room training, policies and procedures.
Verbatim wording from the response “The JESIP Joint Doctrine (edition 3 published in October 2021) sets out principles for joint working between the different services, which SWASFT ensures are implemented through training and its own policies and standard operating procedures. Those principles include communicating using language which is clear, and free from technical jargon and abbreviations.” Source location Response from South Western 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 Extend JESIP course invitations to HM Coastguard colleagues.
Verbatim wording from the response “Invitations to attend JESIP courses are extended to colleagues from HM Coastguard. In addition, SWASFT is currently strengthening relationships by participating in a programme of visits by SWASFT and HM Coastguard commanders and other key role holders to other control rooms. This aims to further promoting shared understanding between SWASFT and HM Coastguard commanders of how each emergency service co-ordinates its response to incidents, and the terminology used by each service. During such a visit the visiting commander shadows the resident control commander, observing processes in operation and listening to communications with officers on-scene.” Source location Response from South Western 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 Implement and routinely exercise a three-way control-room call process enabling direct communication between ambulance, police and fire services during major incidents.
Verbatim wording from the response “In 2019 multiagencies implemented a 3 way call process which can be instigated in the event of a Major Incident, to enable SWASFT and the police and fire services to directly communicate through control rooms. This process enables control rooms to effectively communicate on an open call (or via MSTEAMS in some areas) prior to the arrival of resources at the scene of an incident and facilitates effective command and control in the initial stages of an incident. The setting up of these calls are routinely exercised within the SWASFT EOCs.” Source location Response from South Western Ambulance Service NHS Foundation Trust
Open published response
19 Jan 2021 Vhari Ingall · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information View source Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics View source Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making View source Failure to review TEP/DNAR documents when clinically significant diagnostic information changes View source Failure to limit Do Not Resuscitate document applicability to natural deaths View source See 2 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
Vhari Ingall · 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
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information.
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners . These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death, it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate . In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information .
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review TEP/DNAR documents when clinically significant diagnostic information changes
Wider context from the report “During the Inquest into the death of Vhari I heard evidence from the Senior Partner of her GP surgery, New Court Surgery at Royal Wootton Bassett, Wiltshire as I had a concern in relation to the Treatment Escalation Plan/Do Not Resuscitation (“TEP/DNAR”) form which ████████ had completed with Vhari back in February 2017. I have enclosed a copy of that TEP/DNAR marked “A”. As you will see the reason for issuing it was that Vhari had been diagnosed, late during the previous year, with a pancreatic tumour and she was considered for palliative care only. Towards the end of 2017, the Consultant at Great Western Hospital in charge of her care, reviewed Vhari’s case and the diagnosis changed to one of chronic pancreatitis as opposed to a terminal tumour. This was confirmed in writing to the surgery on the 17 September 2017. During the course of ████████ evidence he explained to me the quite sensible reason why there is no fixed date review of these types of documents but did indicate that such a review was entirely appropriate when it was clinically appropriate to review the TEP/DNAR document. I was firmly of the view that a change in such a fundamental diagnosis should have ordinarily given rise to a review , however, I found no evidence that was recorded in Vhari’s case to suggest that such a review was undertaken by the surgery even though there was a number of consultations with different doctors following Mr. Payne’s letter of September 2017. The notes were completely silent as regards any such review being carried out . In fact I noted an entry in the records on the 5 March 2020 by one of the doctors at the surgery, ████████ who referred to “reminder/alert: DNAR-priority: high.” I also heard evidence from Vhari’s sister, ████████ that in going through Vhari personal possession she found no subsequent TEP/DNAR form after the February 2017 form.
I did consider sending a Regulation 28 Report to the surgery but heard evidence from ████████ that they now have provided by the local CCG an add on to their SystemOne system called an Arden’s module which assists in clinical decision making which they are also using in relation to recording TEP/DNARs. Whilst there is never a 100% guarantee that such a failure to review a document like this will not occur in the future and in respect of Vhari’s case it was in no way contributory to her death, I was satisfied that this step was an improvement and an attempt to mitigate against the risk of such a recurrence.
Obviously, this package is available to surgeries within my own coronial area, but I am unclear as to the position in other areas and obviously you have a greater awareness of these sorts of matters as part of your inspection processes.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit Do Not Resuscitate document applicability to natural deaths
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death , it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations.
” 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 Discuss with commissioners the potential recruitment of mental health practitioners within ambulance clinical hubs.
Verbatim wording from the response “The Trust has also recognised the need to recruit a substantive Senior Mental Health Practitioner to provide ongoing advice and support to staff and to develop services sensitive to the needs of people with mental health issues or a learning disability. This role will provide strategic leadership ensuring mental health remains a key priority for the organisation. They will work with stakeholders to develop pathways of care and services for patients as well as develop guidance and training for staff. One key work stream will be to discuss with commissioners the potential recruitment of mental health practitioners within the ambulance clinical hubs to provide immediate advice to crews.” Source location 2020-0084-Response-from-South-Western-Ambulance-Service_Redacted-1
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 accessible guideline explaining mental health and capacity considerations for patients who self-harm or attempt suicide.
Verbatim wording from the response “It was, however, acknowledged that a more robust review of guidance was required, with a view to developing a more focused guideline identifying the key steps to be considered by crews, in addition to some detailed explanatory text identifying the legislation that underpins it. There ensued a process of collating the relevant information from various sources and incorporating it all into one accessible and easy to comprehend document. A guideline entitled ‘Mental Health and capacity considerations in patients who present as having self-harmed or attempted suicide’ has now been developed by the team, incorporating references to JRCALC (Joint Royal Colleges Ambulance Liaison Committee), NICE and internal SWASFT guidance.” Source location 2020-0084-Response-from-South-Western-Ambulance-Service_Redacted-1
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and deliver mandatory training on the guidance within the 2021/22 staff training package.
Verbatim wording from the response “The Trust will implement the new guideline on 14th October and will notify staff of this together with a briefing of the subject matter via the Chief Executive’s bulletin the same day. Members of the Quality and Clinical Care directorate will then work alongside the Learning and Development team to design training materials to be delivered to staff as part of the 2021/22 staff training package. Given the complexity of the subject matter, it will be important that the content is carefully considered and planned so as to ensure effective delivery to the workforce. Completion of the training is mandatory with the obvious exceptions made for those on maternity and sick leave. In previous years the Trust has routinely achieved 90-95% of the workforce trained with a firm plan to ensure that 100% of the workforce has received their education by the end of Quarter 1 the following year.” Source location 2020-0084-Response-from-South-Western-Ambulance-Service_Redacted-1
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 new guideline and notify staff through a Chief Executive’s bulletin and subject briefing.
Verbatim wording from the response “The Trust will implement the new guideline on 14th October and will notify staff of this together with a briefing of the subject matter via the Chief Executive’s bulletin the same day. Members of the Quality and Clinical Care directorate will then work alongside the Learning and Development team to design training materials to be delivered to staff as part of the 2021/22 staff training package. Given the complexity of the subject matter, it will be important that the content is carefully considered and planned so as to ensure effective delivery to the workforce. Completion of the training is mandatory with the obvious exceptions made for those on maternity and sick leave. In previous years the Trust has routinely achieved 90-95% of the workforce trained with a firm plan to ensure that 100% of the workforce has received their education by the end of Quarter 1 the following year.” Source location 2020-0084-Response-from-South-Western-Ambulance-Service_Redacted-1
Open published response
10 Jul 2018 Eugeniusz Niedziolko · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 8 Arrest culture excluding consideration of drunk-and-incapable arrests View source Inadequate algorithm for assessing deterioration risk in intoxicated people View source Insufficient training and knowledge for assessing alcohol intoxication View source Failure to verify receipt and understanding of critical policies and procedures View source Lack of radio read-back checks for critical information View source Absence of third-party care and deterioration provisions in the 2017 agreement View source Failure to recognise acute alcohol intoxication as a mental disorder or impairment View source Insufficient national police training on mental-disorder implications of acute alcohol intoxication 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.
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AI-generated summary
Eugeniusz Niedziolko · 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
Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Arrest culture excluding consideration of drunk-and-incapable arrests
Wider context from the report “f) ARREST CULTURE - I am concerned having heard evidence in particular from ████████ the former who had been told that you simply do not arrest somebody for being drunk and incapable, the latter having given evidence that there was a culture that you do not arrest for drunk and incapable . If you look at the 2017 multi-party agreement one of the fall-back positions if hospital assistance is not regarded as being necessary is the consideration of arresting that individual for being drunk and incapable. Eugeniusz had no home and was vulnerable as well; the latter confirmed by both ████████ and ████████ so the necessity requirement for arrest would have been satisfied. Eugeniusz was clearly drunk (approaching 5½ times the drink drive limit for blood alcohol) and having become incontinent of urine would also have been regarded as being incapable as I see it. In evidence, the officers regarded Eugeniusz as capable at the time they left him – that alone concerns me in terms of a blinkered view as the bladder would have needed time to refill as the body processes the alcohol and the evidence from the experts pointed to a further period of incontinence prior to death. Eugeniusz was so incapable of looking after himself he was unable to relieve himself appropriately even in a public lavatory. If such a culture exists then that is a concern as it removed here an option that was disregarded by the officers concerned and which if exercised may have resulted in Eugeniusz attending hospital or spending the night safe in custody as opposed to having been left alone in a public lavatory block. I would like you to review the guidance given to frontline officers and to consider emphasising that drunk and incapable is still an arrestable offence if the circumstances and necessity warrant such action being taken to protect life. Arresting an individual does not mean that the person will necessarily be charged.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate algorithm for assessing deterioration risk in intoxicated people
Wider context from the report “g) 2017 AGREEMENT – I raised with Consultant Paramedic ████████, and he is aware of my concern, that given the evidence of ████████ Consultant in Accident & Emergency who gave evidence that even if the observations had been carried out which to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of the 2017 Agreement, I am not convinced that if another Eugeniusz was to crop up that this risk of significant deterioration and death would have been picked up and avoided using this algorithm. Sometimes you have to spell it out and there was no questioning in this case as to when the person last consumed alcohol and over what period and what quantity they had consumed relative to this decision-making process. I queried whether especially with somebody who is not being cooperative as to whether the use of a breathalyser (if they were to consent) would aid in the intelligence gathering. There is also no mention of physical presentation. In Eugeniusz’s case, he had become incontinent of urine in respect of which I asked all relevant witnesses as to how many people they knew who were deliberately incontinent of urine. The answer, not unsurprisingly, was no-one. That factor from the common-sense point of view either is suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to the degree of his intoxication in that he could no longer control and had no awareness of bodily function in that respect. The algorithm needs to be reviewed and considered in the light of this case specifically so that it would pick up another “Eugeniusz”.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and knowledge for assessing alcohol intoxication
Wider context from the report “b) TRAINING AND GENERAL LIFE SKILLS - It was quite clear during the evidence that both police officers had a very limited knowledge in relation to the effects alcohol has on the body . Neither officer asked, nor even attempted to ask, what I would term were obvious questions at the time, namely how much had the individual had to drink and when was the last drink was consumed and over what period the alcohol was consumed. Considering the Courts regard Police Officers as experts in relation to drunkenness (officers tend to provide evidence in relation to drink related offences) neither offered to provide any idea as regards the link between alcoholism and mental health issues; that sex, age and build being all variables can affect how the body processes alcohol; the fact that alcoholics can be quite difficult to judge having regard to tolerance levels (how much they have consumed becoming essential information so as to factor that relevant information to enable a decision to be reached, not just as to what the risk to that individual was at that stage but also in the foreseeable immediate future (in terms of the next few hours or so). The evidence from the Consultant A & E Specialist, ████████ was that there was a poor correlation between visual presentation and the amount of alcohol that might actually be in that individual’s system. I am concerned here that a blinkered approach adopted by officers attending somebody who is intoxicated can easily lead to the wrong decision being taken and one which is based on assumptions. I have been made aware of changes to training programmes but I am concerned that the training does not provide sufficient awareness and that there may be still a significant number of officers who simply do not have the life experience and general knowledge to factor that experience into professional judgement making. It would not surprise me if your officers in Swindon, more likely than not, have a better awareness of these issues and perhaps they could look to improve the training and share their experiences to officers elsewhere in the County.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify receipt and understanding of critical policies and procedures
Wider context from the report “d) COMMUNICATION OF POLICY AND PROCEDURE
I am aware that following this incident the 2009 Agreement between the Hospitals, Ambulance Trust and Wiltshire Police as regards the assessment of people who appear to be drunk and need of medical assessment was circulated. A newer agreement was also subsequently entered into in June 2017. I am surprised and concerned that even now front-line officers, who gave evidence, were unaware of either of these 2 agreements. It would appear that important communications are being sent out but that there is no effective system in place to check that the important information is received and more importantly is understood . This also applies to e-learning which is capable of abuse if the same questions are asked at the end of modules. Interestingly, I heard from Consultant Paramedic, ████████ that in relation to their e-learning systems random questions are asked at the end of e-learning modules in an attempt to overcome the risk of abuse. I fully appreciate that front line officers are under huge amounts of pressure with increasing workloads and less resources but my fear is that there will be a repeat of this incident and other issues arising that may lead to a death occurring through the lack of effective communication of policies and procedures which, at the end of the day, are designed to guide front line personnel and ultimately protect them. With busy workloads, an expectation that these documents will be read is unrealistic and arguably idealistic.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of radio read-back checks for critical information
Wider context from the report “a) RADIO PROTOCOL
When listening to the radio communications there appeared to be a non-existent radio protocol of any form . My concern relative to this particular point is the absence of a protocol which for example requires the recipient of important information such as PNC markers to reflect or even repeat the information that has been given so that it can be established both ends that the information has been correctly and effectively communicated. The situation that appears to have arisen in this case is that the controller says that all 3 markers were communicated but the transcript supports the 2 officers on the ground recollections that they only received notification of 1. I am concerned that the absence of any check could lead to critical information not being communicated which could lead in certain circumstances to errors occurring that could result in a worst case scenario to a death occurring. This issue of relaying critical information was highlighted by the jury in their Narrative Conclusion.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of third-party care and deterioration provisions in the 2017 agreement
Wider context from the report “e) 2009 & 2017 MULTI PART AGREEMENT (copies enclosed) - As regards the Agreement in 2009, I noted with interest insofar as the Ambulance protocol was concerned that a risk of deterioration should be assessed and that the patient should be left in the care of a 3rd party , with advice on seeking medical assistance later if required. I am concerned and have aired as to why this is absent from the 2017 Agreement and also I am concerned as to why consideration is not given for a similar provision being incorporated into the police protocol in the 2017 Agreement . Such a measure appears to be eminently sensible as a matter of common sense.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise acute alcohol intoxication as a mental disorder or impairment
Wider context from the report “c) AWARENESS OF MENTAL HEALTH ISSUES
I have already highlighted a concern with the 2 officers in question who were unaware of the link between mental health and alcoholism that runs in both directions. What was more concerning was that both officers were unaware that acute alcohol intoxication amounts to a mental disorder for the purposes of the Mental Health Act 1983 and a mental impairment for the Mental Capacity Act 2005 . This point is being addressed below to the Chief Executive of the College of Policing and also the Council of Chief Police Officers Mental Health Lead as I suspect that the 2 officers involved in this case, as indeed every other Police Officer who gave evidence, was unaware of this until recently. This needs to change as a matter of urgency as in this case the use of Section 136 Mental Health Act 1983 was never considered as an option because neither officer thought that Eugeniusz was suffering from a mental disorder . ████████ a consultant psychiatrist also expressed a view to the court that he doubted that Eugeniusz actually had mental capacity when appearing to agree to being left in the lavatory block.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient national police training on mental-disorder implications of acute alcohol intoxication
Wider context from the report “i) I hope in reaching this stage of the report that you will have read the points made above and you will be aware of my concern that until recently it would appear that the College of Policing and police officers within Wiltshire were unaware that acute alcohol intoxication is regarded as being a mental disorder for the purposes of the Mental Health Act 1983 and a Mental impairment for the purposes of the Mental Capacity Act 2005 (although senior Wiltshire Officers have or should have been aware of this concern since June 2017). The code of practice in relation to the Mental Health Act 1983 highlights this and as I understand ever since 1993 acute alcohol intoxication has been recognised by the World Health Organisation in ICD-10 relating to mental and behavioural disorders with acute alcohol intoxication being classified at F10 as being such a mental disorder. Front line officers need to be aware of such matters so that when dealing with situations that confront them that they have a full awareness and understanding of the range of options and powers that they may have available to them. I fully accept and understand the point that I made in Court that Section 136 of the Mental Health Act 1983 should be sparingly used but that does not mean that it should not be used because the officers concerned do not recognise that the person in front of them has a mental disorder so that they can then go on to consider whether or not the person is in need of immediate care and control and ultimately a mental health assessment. In this case they did not consider Section 136 simply because they did not think that Eugeniusz was suffering from a mental disorder at the time . I would ask you to review the training that is provided nationally to all Police Forces in this respect.
” Open source report
22 Nov 2017 Susan Ann Smalley · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Insufficient ambulance resources to meet demand in the Gloucestershire area View source Lack of clarity about which hospital should treat the patient View source Failure to appropriately expedite urgent emergency transfers between hospitals 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
Susan Ann Smalley · 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
Susan Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance resources to meet demand in the Gloucestershire area
Wider context from the report “1. The sufficiency of ambulance resources that have been allocated to meet demand in the Gloucestershire 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about which hospital should treat the patient
Wider context from the report “2. Whether clinicians, patients and paramedics are clear as to which hospital, either Gloucester Royal Hospital or Cheltenham General hospital, should be treating 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately expedite urgent emergency transfers between hospitals
Wider context from the report “3. When urgent emergency transfers are requested between hospitals, how they are appropriately expedited .
” Open source report
21 Jun 2017 Colin James SLUMAN · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Insufficient availability of Clinical Supervisors to advise call handlers on appropriate responses View source Failure of the emergency response protocol to include dizziness and being alone as important triggers for rapid response to catastrophic haemorrhage View source Lack of clinical training for call handlers View source Failure to provide constant clinical oversight of all emergency reports 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
Colin James SLUMAN · 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
Colin James SLUMAN suffered a burst varicose vein and exsanguinated before emergency services attended. Concerns included that the NHS Pathways protocol did not treat dizziness and being alone as triggers for a rapid response to catastrophic haemorrhage, that call handlers were not clinically trained and relied on the protocol, and that clinical supervision was not continuously available.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of Clinical Supervisors to advise call handlers on appropriate responses
Wider context from the report “(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times , nor do they have constant oversight of all emergency reports.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency response protocol to include dizziness and being alone as important triggers for rapid response to catastrophic haemorrhage
Wider context from the report “(1) The protocol supplied by NHS Pathways to South Western Ambulance Service Trust (SWAST) call handlers does not include reports of “dizziness” and “patient on their own” as important triggers for a rapid response to a report of catastrophic haemorrhage .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical training for call handlers
Wider context from the report “(2) Call handlers are not clinically trained and are completely reliant on the Protocol for categorising responses (in this case amber was used).
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant clinical oversight of all emergency reports
Wider context from the report “(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports .
” 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 Introduce a cross-hub hunt group enabling EMAs to obtain support from available clinicians.
Verbatim wording from the response “In response to continual increases in call volume, the Trust has implemented a virtual telephony system to ensure an available call handler, irrespective of location, will take a 999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are able to seek clinical support from available clinicians irrespective of their hub location, thereby maximising the clinical support available to call handling staff.” Source location 2017-0200-Response-by-South-Western-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 Add major blood loss categories to the Clinical Supervisors’ Escalation Report.
Verbatim wording from the response “A further system utilised by clinicians within the hub is the Escalation Report. This is a tool on the administrative computers on each Clinical Supervisor’s desk and is designed to assist clinicians to identify incidents that have been triaged to an ‘Amber’ disposition but may be in need of a higher level of urgency. It only includes those incidents where an ambulance has yet to be allocated and relates to those categories of call that have the potential to be life-threatening, as in this instance. A Clinical Supervisor can then review the incidents highlighted by this report and decide whether to call the patient for further triage and upgrade the call where required. Before this incident, ‘major blood loss’ (without other symptoms) did not appear as a category identified on the Escalation report.” Source location 2017-0200-Response-by-South-Western-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 clinicians’ rota arrangements to align availability with demand by time and day.
Verbatim wording from the response “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.” Source location 2017-0200-Response-by-South-Western-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 Put funding in place to recruit ten additional clinicians.
Verbatim wording from the response “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.” Source location 2017-0200-Response-by-South-Western-Ambulance-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation EMAs are not completely reliant on NHS Pathways because clinical escalation, local guidance and supervisory review provide additional safeguards.
Verbatim wording from the response “In terms of whether EMAs are completely reliant on NHS Pathways to reach a disposition, as the Pathways are meticulously devised by a panel of clinical experts, EMAs are for the most part, able to rely on the disposition reached. However, there are occasions where the Trust does not consider a particular disposition (as would be generated by NHS Pathways) for a specific patient presentation to be appropriate despite being clinically safe. On those occasions, the issues are escalated to NHS Pathways for review. Although the Pathways may be revised as a result, if change is not felt to be clinically necessary, it is for the Trust to determine whether local guidance or SOPs should be implemented to govern a particular situation and accordingly any policies would need to be ratified through internal governance procedures.” Source location 2017-0200-Response-by-South-Western-Ambulance-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways considered that adding a dizziness question to the bleeding pathway would not have increased the response disposition.
Verbatim wording from the response “Following the incident, concerns regarding the bleeding Pathway were quickly identified and escalated by the Trust’s Clinical Lead to NHS Pathways for consideration. The concern as to whether a question relating to dizziness should be incorporated within the bleeding Pathway was first raised on 15th July 2016. The Serious Incident investigation report highlighting these concerns was also shared with their organisation in December 2016. It is the Trust’s understanding that NHS Pathways has considered the concerns raised and do not feel that the addition of a question about dizziness would have raised the disposition level.” Source location 2017-0200-Response-by-South-Western-Ambulance-Service
Open published response
Concerns raised 4 Failure to appropriately manage the incident scene and patient safety and dignity View source Delays in attending and transferring emergency patients View source Failure to inform police of road traffic accidents in a timely fashion View source Failure to appropriately triage and manage emergency 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
William Robert Raymond Nute · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately manage the incident scene and patient safety and dignity
Wider context from the report “That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately . For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway .
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in attending and transferring emergency patients
Wider context from the report “That the delay in attending and transferring Mr Nute increased his risk of not recovering from his fall/fracture or the trauma of the incident which in turn increasing his risk of death.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform police of road traffic accidents in a timely fashion
Wider context from the report “That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately. For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately triage and manage emergency calls
Wider context from the report “That the 999 calls from the public were not triaged by the call handlers at BT or South Western Ambulance appropriately and managed .
” 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 Participate in cross-emergency-service forums to discuss and address operational issues, incidents and improvements to collaborative working and communication.
Verbatim wording from the response “In an attempt to ensure we work to continuously improve our working relationship with other emergency services, including Devon and Cornwall Police, representatives from the Trust attend a number of different meetings which provide a platform for any issues or concerns to be discussed and addressed. These include:” Source location 2016-0229-Response-by-South-Western-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 Participate as a trial site in the Ambulance Response Programme’s new call-coding system.
Verbatim wording from the response “ARP has now developed a new call coding set which has been trialling in two sites - South Western Ambulance Service NHS Foundation Trust and Yorkshire Ambulance Service for a minimum of 12 weeks since April 2016.” Source location 2016-0229-Response-by-South-Western-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 original emergency call was triaged correctly, achieving 97% compliance against the applicable 86% pass rate.
Verbatim wording from the response “In terms of the question as to whether the call received was triaged appropriately, I can confirm that ████████ investigation confirmed that the disposition reached for the original call was indeed correct. An audit of this call was undertaken as part of the investigation, which confirmed the call achieved 97% compliance against a pass rate of 86%. That said, it is acknowledged that the police were not notified of the incident until 12.56, an hour after the original call had been received. I am aware that concerns were raised during the inquest that the delay in notifying the police could have led to the driver of the vehicle leaving the scene and furthermore, placed a responsibility on those members of public on scene to effectively shield Mr Nute from passing traffic.” Source location 2016-0229-Response-by-South-Western-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 journey to hospital was delayed by only 15 minutes because the crew took the quickest ordinarily available route despite vehicle difficulties.
Verbatim wording from the response “In terms of the concerns received regarding a delay in conveying Mr Nute to hospital, a review of our systems has confirmed that the crew left scene at 14.55 and arrived at the Royal Cornwall Hospital Trust at 16.14, with a journey time of 1 hour and 20 minutes. I understand the crew encountered a couple of difficulties with the vehicle on the way to hospital which meant they had to stop on a couple of occasions for a few minutes. I am advised, however that the crew took the quickest route to the hospital which would ordinarily take 1 hour 5 minutes. This meant there was a delay to hospital but only by 15 minutes.” Source location 2016-0229-Response-by-South-Western-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 Immediate conveyance was unavailable because all suitable ambulance resources were committed to higher-priority, time-critical patients.
Verbatim wording from the response “After conducting an initial assessment of the patient, the ECP made a request for priority 2 back-up at 12.40, after being on scene for 4 minutes. Regrettably, a DCA was not immediately available, as all resources were committed. The next available conveying resource was therefore allocated at 13.12 and arrived on scene at 13.44.” Source location 2016-0229-Response-by-South-Western-Ambulance-Service-NHS-Trust
Open published response
3 Sep 2015 Ms. Kala Michelle Skinner · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure to recognise critical clinical red flags View source Failure to audit at least 3% of Clinical Advisor calls every month View source Absence of a safety net to identify potential risks or training needs View source Failure to make sufficient and timely welfare calls when no response is provided View source Failure to provide appropriate safety-focused clinical advice View source See 2 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
Ms. Kala Michelle Skinner · 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
On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise critical clinical red flags
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit at least 3% of Clinical Advisor calls every month
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors . In some months no audits at all have been performed .
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a safety net to identify potential risks or training needs
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs .
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make sufficient and timely welfare calls when no response is provided
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided .
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate safety-focused clinical advice
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased .
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” Open source report
8 May 2015 Michael Lawrence HACKER · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to maintain ambulance service policy appropriately addressing the Mental Capacity Act View source Failure to provide ambulance service training appropriately addressing the Mental Capacity Act 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
Michael Lawrence HACKER · 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
Michael Lawrence HACKER, aged 66, refused hospital admission for treatment of gangrene and was assessed as lacking capacity to refuse admission on 19 December 2014. He died at home on 28 December 2014 from gangrene of the foot, with type 2 diabetes mellitus. The report raised concerns about ambulance service training and policy concerning the Mental Capacity Act, including whether restraint or force could be used when a person lacking capacity refused hospital transfer.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain ambulance service policy appropriately addressing the Mental Capacity Act
Wider context from the report “1. ████████ an Advocacy and Locum Consultant IMCA expressed in evidence his concerns in relation to the ambulance service in this particular case. I heard evidence that South West Ambulance Services Trust had attended Mr. Hacker previously to take him to hospital for treatment of his gangrene and had not been successful in persuading Mr. Hacker to go with them.
████████ contacted ████████ from the South West Ambulance Services Trust before and after Mr. Hacker's death to be told that if an ambulance turned up at the property then there was a protocol in place that meant that the crew would not use restraint or apply force if Mr. Hacker did not want to go with them . ████████ expressed concerns as to the Trust's policy around the Mental Capacity Act .
If Mr. Hacker had been taken to hospital sooner he may or may not have received treatment depending on a number of factors including his capacity to make decisions. I did not make any criticism around the ambulance service in this case however it did raise a concern with me about prevention of future deaths.
I am therefore writing this report to ask that you consider your training and policy around the Mental Capacity Act
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ambulance service training appropriately addressing the Mental Capacity Act
Wider context from the report “1. ████████ an Advocacy and Locum Consultant IMCA expressed in evidence his concerns in relation to the ambulance service in this particular case. I heard evidence that South West Ambulance Services Trust had attended Mr. Hacker previously to take him to hospital for treatment of his gangrene and had not been successful in persuading Mr. Hacker to go with them.
████████ contacted ████████ from the South West Ambulance Services Trust before and after Mr. Hacker's death to be told that if an ambulance turned up at the property then there was a protocol in place that meant that the crew would not use restraint or apply force if Mr. Hacker did not want to go with them. ████████ expressed concerns as to the Trust's policy around the Mental Capacity Act.
If Mr. Hacker had been taken to hospital sooner he may or may not have received treatment depending on a number of factors including his capacity to make decisions. I did not make any criticism around the ambulance service in this case however it did raise a concern with me about prevention of future deaths.
I am therefore writing this report to ask that you consider your training and policy around the Mental Capacity Act
” Open source report
5 Aug 2014 Clare Louise BAIN · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure to correctly identify the opiate overdose and assess the adequacy of a single naloxone dose View source Failure to provide repeat naloxone treatment doses while opiates remain active View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clare Louise BAIN · 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
Clare Louise BAIN, who was prescribed Methadone and Valium, was found collapsed after ingesting a fatal quantity of prescribed and non-prescribed Methadone and Valium. She initially responded to Naloxone but later suffered cardiac arrest and died. The concerns were that paramedics may have treated the incident as a heroin overdose and that insufficient repeat Naloxone could fail to counteract the longer respiratory-depressant effects of Methadone.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly identify the opiate overdose and assess the adequacy of a single naloxone dose
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate .
(2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide repeat naloxone treatment doses while opiates remain active
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate.
(2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active .
” 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 Issue a clinical notice guiding clinicians on methadone overdose treatment, hospital conveyance, refusal of transport, monitoring and escalation.
Verbatim wording from the response “On the 1st October, the Trust will be issuing further guidance for clinicians to raise awareness of methadone overdose and how it should be treated. The guideline will highlight:” Source location 2014-0359-Response-by-South-Western-Ambulance-Service
Open published response
7 Apr 2014 Roger Clive DUGGAN · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 3 Failure to respond sufficiently seriously and promptly to mental health crisis calls View source Failure to ensure staff responsibility for observing an agitated patient in the emergency department View source Lack of staff training to deal with mental health crisis 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
Roger Clive DUGGAN · 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
Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.
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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond sufficiently seriously and promptly to mental health crisis calls
Wider context from the report “(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend .
It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff responsibility for observing an agitated patient in the emergency department
Wider context from the report “(2) Mr Duggan was brought to the Emergency Department of the Royal Devon & Exeter Hospital (Wonford) late on the evening of the 10th February 2013 in a state of heightened anxiety and agitation.
Night Senior Nurse Mental Health Practitioner, ████████ was called to assess. I received Evidence that ████████ left the Deceased in cubicle 8 in Minors area (which was supervised) asking the staff nurse to sit with Mr Duggan while he spoke with the family. He was told that they would keep an eye on Mr Duggan.
No one saw Mr Duggan leave the cubicle until the CCTV picked up his exit from the unit at 00.47 hours on 11th February 2013.
It appears from Evidence that neither the Senior Nurse Mental Health Practitioner not night staff on the unit took responsibility for watching Mr Duggan.
Mr Duggan was found Deceased in the River Exe at 14.30 hours 12th February 2013.
” 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 Western Ambulance Service NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training to deal with mental health crisis
Wider context from the report “(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend.
It appears that staff lacked the necessary training to deal with Mental Health Crisis . After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations