15 Nov 2023 Lauren Page Smith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 8 Gap in fitness-to-practise oversight for unregistered technicians View source Failure to assess and manage staff fitness to practise after identified deficiencies View source Failure of the ambulance service to implement collective learning from identified ECG training gaps View source Failure to correctly interpret 12 lead ECGs View source Failure to note or act upon auto-diagnostic ECG reports View source Failure to provide accurate information about observations and ECG findings View source Lack of qualitative assessment of ECG training View source Lack of further ECG training after identified incorrect interpretation View source See 5 more concerns
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Lauren Page Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.
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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Gap in fitness-to-practise oversight for unregistered technicians
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████ . ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time . I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage staff fitness to practise after identified deficiencies
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles . I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Failure of the ambulance service to implement collective learning from identified ECG training gaps
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████ . There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician . Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Failure to note or act upon auto-diagnostic ECG reports
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report .
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about observations and ECG findings
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct , and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Lack of qualitative assessment of ECG training
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training . I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time .
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 University of Wolverhampton; that does not assign responsibility.
PFD Monitor interpretation Lack of further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Organise continuing professional development ECG masterclasses for registered paramedics.
Verbatim wording from the response “▪ The University will organise continuing professional development ECG masterclasses to offer to registered paramedics” Source location Response from University of Wolverhampton
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 Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.
Verbatim wording from the response “▪ Evidence from the case will be presented to students to exemplify the potential harm from inadequate understanding of the ECG and the implications for the patient – we would welcome a copy of the ECG if this is possible” Source location Response from University of Wolverhampton
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 Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.
Verbatim wording from the response “▪ Interpretation of 12-lead ECGs will be incorporated into one or more of the Objective Structured Clinical Examinations that students sit throughout their programme. This will supplement rather than replace the current assessments in practice.” Source location Response from University of Wolverhampton
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 Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.
Verbatim wording from the response “▪ Members of the paramedic team are liaising with local coronary care units to obtain anonymised 12-lead ECG readings from real patients to further enhance the teaching” Source location Response from University of Wolverhampton
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.
Verbatim wording from the response “▪ A 12-lead ECG interpretation workbook will be added to the virtual learning environment for completion by students. Students who do not complete the activity will be followed up by their personal academic tutor” Source location Response from University of Wolverhampton
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.
Verbatim wording from the response “The University understands and accepts without reservation that its training must be effective. We have reviewed all of the ECG training and assessment that takes place on the programme and are confident that our teaching fully covers the abnormalities found in the ECG in this case, the pathological implications of such findings, and the appropriate course of action to be taken.” Source location Response from University of Wolverhampton
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A fitness-to-practise referral was considered unlikely to meet referral criteria given the employment context, remaining training and registered-paramedic supervision.
Verbatim wording from the response “At the time of the incident, ████████ was working as an employee of WMAS and not in her capacity as a student on placement. As such, WMAS did not notify the University of the incident and we remained unaware of it until two days prior to the receipt of the Regulation 28 report. Had we known earlier, we may have considered whether a referral to an FtP panel was appropriate, but it seems unlikely that the event would have met the criteria for referral. ████████ still had over 15-months of her programme remaining (including the sessions on ECGs), and she was working with a registered paramedic who held overall responsibility and accountability for the decisions made.” Source location Response from University of Wolverhampton
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 Student placement risks are ameliorated because a registered paramedic supervises students and remains responsible and accountable for patient care.
Verbatim wording from the response “████████ commenced her education at the University in June 2022, and is not due to complete her studies until January 2024. It is important to emphasise, that ████████ is not a registered paramedic and will not be eligible to apply for professional registration until such time as she has met all of the outcomes of her current programme of study. As a student, ████████ does not have all of the competencies and skills of a registered paramedic so would be working with a practice educator who is there to support and supervise her as she develops those competencies and skills. It is not expected that she would be making independent decisions on patient care whilst in her role as a student paramedic. The practice educator will always have the ability to override the decision of a student should they deem the proposed course of action to be sub-optimal for the patient.” Source location Response from University of Wolverhampton
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 At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.
Verbatim wording from the response “It should also be noted that on the 6 January 2023, ████████ was working as an employee of WMAS and was not there in her student capacity. ████████ was working within the remit of an associate ambulance practitioner.” Source location Response from University of Wolverhampton
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations