Concerns raised 7 Failure to produce timely final reports and interim statements on investigation progress and safety issues View source Failure to recognise oxygen fires and immediately cut off the oxygen supply View source Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires View source Failure to prevent cigarettes and related flammable items and materials in the cockpit View source Unavailability of protective equipment for cockpit fires View source Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence View source Failure of risk analyses to account for overpressure in the oxygen distribution system 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
Richard Mohamed Fekry Osman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Mohamed Fekry Osman was a passenger on flight MS804, which crashed into the Mediterranean Sea on 19 May 2016 after a fire broke out on the flight deck; there were no survivors. The inquest stated that the fire was caused by an ignition source of unknown origin, most likely associated with the first officer’s oxygen supply system. The substantive concerns included cockpit fire and smoke procedures, oxygen-system risks, fire-protection equipment and extinguishers, smoking regulations, and arrangements for participation in or transfer of aircraft accident investigations.
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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely final reports and interim statements on investigation progress and safety issues
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise oxygen fires and immediately cut off the oxygen supply
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent cigarettes and related flammable items and materials in the cockpit
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Unavailability of protective equipment for cockpit fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence ;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of risk analyses to account for overpressure in the oxygen distribution system
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report
Concerns raised 8 Failure of Emergency Care Assistant and Emergency Medical Technician crews to adhere to the EoE PPCI protocol after PPCI referral View source Lack of training and instruction for Emergency Care Assistants and Emergency Medical Technicians in ECG machine operation and interpretation View source Failure to provide Emergency Care Assistants and Emergency Medical Technicians with attendance at Immediate Life Support courses View source Failure to ensure clinicians with current ALS training attend transfers after activation of the Primary Percutaneous Coronary Intervention protocol View source Failure of ambulance crews to inform community referrers of their life-support training scope View source Lack of specific guidance for contact and continuing dialogue with relatives after next of kin details are established View source Failure to assess Emergency Care Assistants and Emergency Medical Technicians at intervals for compliance with life-support standards and scope of practice View source Failure to ensure ALS-trained clinicians attend Code Red ambulance transfers for patients with acute coronary syndrome View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
STEPHEN ANTHONY BEDFORD · 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
Stephen Anthony Bedford, aged 33, experienced chest pain at a gym on 31 July 2012, collapsed at a health centre, and was diagnosed with an ST elevation myocardial infarction before being transferred to Papworth Hospital, where his death was confirmed. The inquest recorded acute myocardial ischaemia and coronary artery thrombosis, and stated that the outcome might have been different with a more timely transfer to the specialist coronary intervention centre. Concerns included ambulance staff assessment and training, the attendance of appropriately trained paramedics on transfers, adherence to the PPCI protocol, ECG training, and communication with relatives.
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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Care Assistant and Emergency Medical Technician crews to adhere to the EoE PPCI protocol after PPCI referral
Wider context from the report “5. Whether the Trust’s ECA and EMT crews should be made familiar with and instructed to adhere to the EoE PPCI protocol following any PPCI referral from the community or hospital and whether practical guidance in support of the protocol should be given on the lines suggested in the appendix attached.
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of training and instruction for Emergency Care Assistants and Emergency Medical Technicians in ECG machine operation and interpretation
Wider context from the report “6. Whether ECA’s and EMT’s should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether they should attend the Trust’s ILS Courses.
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Emergency Care Assistants and Emergency Medical Technicians with attendance at Immediate Life Support courses
Wider context from the report “6. Whether ECA’s and EMT’s should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether they should attend the Trust’s ILS Courses .
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinicians with current ALS training attend transfers after activation of the Primary Percutaneous Coronary Intervention protocol
Wider context from the report “4. Whether the Trusts paramedics, or only those with current ALS training should be mandated to attend all transfers post-activation of the Trusts Primary Percutaneous Coronary Intervention protocol ( Eo PPCI) , as stipulated in that protocol.
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance crews to inform community referrers of their life-support training scope
Wider context from the report “(3) Whether at the point of community referral (patient’s home, GP surgery or elsewhere) the referring individual or team are made aware by the ambulance crew of the scope of their training(i.e. BLS, ILS or ALS) to ensure an informed and optimal decision on transfer is 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for contact and continuing dialogue with relatives after next of kin details are established
Wider context from the report “7. Whether contact with and continuing dialogue with relatives should be the subject of specific guidance once next of kin details have been established ,
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to assess Emergency Care Assistants and Emergency Medical Technicians at intervals for compliance with life-support standards and scope of practice
Wider context from the report “(1) Whether the Trust’s Emergency Care Assistants (ECA) and Emergency Medical Technicians (EMT) are assessed at intervals to ensure compliance with Basic Life Support(BLS) and Immediate Life Support (ILS) standards and scope of practice .
” 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 Stewarts Law LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ALS-trained clinicians attend Code Red ambulance transfers for patients with acute coronary syndrome
Wider context from the report “(2) Whether the Trust’s paramedics or otherwise only those with Advanced Life Support (ALS) training should be mandated to attend all Code Red ambulance transfers of patients diagnosed with acute coronary syndrome(ACS)
” 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