Concerns raised 9 Lack of careline policy, guidance and training for third-party emergencies View source Failure to recontact the EMA when a caller reports deterioration View source Failure to record clinically relevant information in EMA notes View source Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing View source Failure to check and improve the quality of clinical note taking View source Inadequate quality of the call auditing system View source Failure to obtain and pass on key emergency information from careline callers View source Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement View source Failure to obtain or provide basic clinical advice during careline emergency calls View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Derek Thomas Burt · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Lack of careline policy, guidance and training for third-party emergencies
Wider context from the report “2) I also heard from the careline centre manager that Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves. It was good to learn that both careline operators did respond positively to the cry for help from Mrs Burt. I remained concerned, however, that there is no policy or guidance available for operators to cover this type of emergency or life threatening situation and no training has yet been devised to learn from the unusual circumstances that occurred here .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recontact the EMA when a caller reports deterioration
Wider context from the report “In addition, the first careline operator did not call the EMA back when she learned Mr Burt was non responsive and had developed breathing problems . The CSN confirmed to me that if a second call had been made at that point then the call would have been upgraded to category 1 . This would have been at approx 22:50. In other words around the same time the EMA was trying to call Mrs Burt back. The clinical review was allocated at 22:55 and the second 999 call was logged at 23:15 so approximately 20-25 mins had elapsed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinically relevant information in EMA notes
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review .
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing
Wider context from the report “1) I heard evidence from the call centre manager of Appello Careline and the first careline operator that their system had the capability to speak directly to Mrs Burt without her pressing her wrist alarm button as this could have been done via the digital base unit that was in her bedroom. The system can also set up a 3 way conversation or conference call to include any of the emergency services. Indeed the operator told me she has done this in the past if asked to do so by the emergency services or she has suggested it but she did not do so in this case as she took heed from the EMA.
Conversely, I heard from a CSN with South East Coast Ambulance Service (SECAMB) that she did not know careline companies could set up 3 way conference calls for a CSN to speak to the patient or helper directly. She knew that Police and Fire Services used 3 way conference calls using careline systems but not Ambulance Trusts.
This case had moved from the dispatch to the clinical stack and from the timeline of calls supplied it seems 15 calls were made between 22:52 and 23:23 to the landline and mobile numbers supplied but of course, it was impossible for Mrs Burt to answer them.
No one thought to go back through the digital base unit to offer the basic clinical advice that was needed. I am concerned that both Ambulance Trusts generally as well as Careline companies may not be aware of the potential to save lives using available technology.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to check and improve the quality of clinical note taking
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others . Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of the call auditing system
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and pass on key emergency information from careline callers
Wider context from the report “3) I also remain concerned that the first careline operator did not pass on a key piece of information to the EMA, namely that the caller did not have access to a phone . Nor did she ask if the blood was spurting or dribbling . Although, it was relayed that Mrs Burt was bedbound, the EMA would not have realised that Mrs Burt couldn’t get to the phone as it was in another room.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement
Wider context from the report “6) I was told that SECAMB is taking part in a pilot called Tortoise looking at using AI to improve the accuracy of note taking. It was unclear whether a similar scheme is being explored by careline companies or if there is effective liaison between careline companies and ambulance trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or provide basic clinical advice during careline emergency calls
Wider context from the report “5) I heard that an EMA can hold a call and speak to a CSN to get basic first aid advice or join the CSN into the call . Given the volume of blood that had already been lost in this case, I am concerned that this opportunity to give clinical advice was lost especially as the call had come in via a careline operator.
” Open source report
4 Apr 2025 Mr YZ · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Failure of careline guidelines to accommodate users with impaired communication and cognitive processing 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
Mr YZ · 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
Mr YZ died at home on 2 March 2024 from extensive blood loss following a traumatic open fracture of the right ankle. He activated his emergency careline but did not receive medical assistance after the operator treated the brief call as accidental. The principal concern was that careline procedures and questioning may fail to identify serious injury in users with impairments similar to those associated with Huntington’s Disease.
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 TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure of careline guidelines to accommodate users with impaired communication and cognitive processing
Wider context from the report “(1) YZ’s presentation with Huntington’s Disease involved altered pain pathways/responses, slurred speech, lack of or reduced insight, tendency to apathy and self-neglect and impaired cognitive processing.
(2) These are aspects of presentation that may be present in a wider group of other end-users of careline services (for example those with dementia) and are not limited to end-users with Huntington’s Disease.
(3) I found there was a missed opportunity to obtain life-saving medical assistance that was attributable to YZ’s impairments arising from Huntington’s Disease.
(4) YZ had called for assistance but the operator failed to identify that he had a major injury with significant blood loss.
(5) The interaction was very brief, YZ contributing only a few words, and I found key information might have been elicited if YZ had been given more time, asked to repeat his unintelligible opening words, or had been asked open and/or more specific closed questions.
(6) I found the operator who answered the call was trained and had followed the protocols that were in place for him at that time. He was not a clinician. His management of the call was in line with the guidelines applicable to his work (Appello Careline Limited guidelines, and the guidelines of the Telecare Services Association, which are followed by most of the careline services industry).
(7) After YZ’s death Appello Careline Limited quickly and proactively reviewed their procedures and amended their call protocols. At inquest they accepted the offer of the Huntington’s Disease Association to work with them to identify questioning methods or protocols that might further reduce the risk of similar outcomes in future.
(8) The Telecare Services Association was not a recognised interested person in YZ’s inquest.
(9) I am bringing a risk formally to their attention with this report. The risk is to careline users with similar presentations as YZ if the Telecare Services Association’s guidelines continue unamended.
” Open source report
4 Oct 2022 Reginald Cauthery · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to review telecare services in light of increased fire risk and deteriorating mobility View source Failure to answer telecare fire calls as a priority View source Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance View source Smoke alarms not connected to telecare systems View source Delays in calling 999 while seeking confirmation of smoke alarm activation 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
Reginald Cauthery · 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
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
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 TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review telecare services in light of increased fire risk and deteriorating mobility
Wider context from the report “(1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility .
” 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 TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Failure to answer telecare fire calls as a priority
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority . In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade . This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare 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 TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Smoke alarms not connected to telecare systems
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare 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 TSA – The Voice of Technology Enabled Care; that does not assign responsibility.
PFD Monitor interpretation Delays in calling 999 while seeking confirmation of smoke alarm activation
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call .
” 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