Concerns raised 3 Difficulties in locating the appropriate cardiac-arrest Naloxone guidance on the JRCALC app View source Insufficient Naloxone stock carried per ambulance for opioid-related cardiac arrest View source Inability of attending paramedics to comply with opioid-related respiratory-arrest and cardiac-arrest guidelines amid competing tasks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Wayne AUSTIN · 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
Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024 after reporting that he had consumed cider; paramedics were subsequently informed that he had consumed crack cocaine. He was treated with CPR, advanced life support and Naloxone, transferred to hospital, and died as a result of combined buprenorphine and alcohol toxicity. Concerns included difficulty locating and applying the appropriate Naloxone guidance, the practical difficulty of complying with dosing guidelines during cardiac arrest, and the number of Naloxone vials carried by ambulances.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in locating the appropriate cardiac-arrest Naloxone guidance on the JRCALC app
Wider context from the report “(1) Difficulties in locating the appropriate tab for cardiac arrest (where opioid toxicity is the likely cause) on the JRCALC app for Naloxone meant it was missed and not applied
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient Naloxone stock carried per ambulance for opioid-related cardiac arrest
Wider context from the report “(3) WMAS ambulances only carry a box of 10 Naloxone 400mg vials per ambulance which means that one ambulance attending a situation such as Wayne’s would be insufficient to deal with the circumstances, as would two ambulances . It would mean that three ambulances are required to comply with cardiac arrest (where opioid toxicity is the likely cause) .
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of attending paramedics to comply with opioid-related respiratory-arrest and cardiac-arrest guidelines amid competing tasks
Wider context from the report “(2) Inability of attending paramedics to comply with the guidelines for Respiratory arrest/depression due to other competing tasks and therefore certainly a complete inability to comply with the guidelines for cardiac arrest (where opioid toxicity is the likely cause) making them potentially unrealistic .
” 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 Raise the practical and evidential concerns about cardiac-arrest Naloxone Hydrochloride guidance with JRCALC for consideration in its guidance review.
Verbatim wording from the response “Overall, this issue reflects a disconnect between guideline intent and what is operationally achievable during cardiac arrest resuscitation, rather than an unreasonable failure to follow guidance. WMAS considers that, in this context, the guideline may not be fully realistic for frontline application and should be interpreted pragmatically, with patient-centred prioritisation of core life-saving interventions. The WMAS Medical Director has raised these points with JRCALC, and it is our understanding that the Naloxone Hydrochloride guidance will be reviewed.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete formal clinical reviews of ambulance Naloxone Hydrochloride quantities and confirm the current ten-ampoule load list remains appropriate.
Verbatim wording from the response “WMAS has undertaken formal clinical review of this issue. An initial review of Naloxone Hydrochloride quantities was completed in May 2025 by the WMAS Consultant Paramedic for Emergency Care, followed by a further review in September 2025 by the senior clinical team. The latter specifically considering the cardiac arrest guidance where opioid overdose is suspected. The consensus from the latest review was that the current Naloxone Hydrochloride quantities carried on the WMAS Load List were appropriate.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The recommended maximum naloxone stock is not a realistic operational benchmark because benefit during established cardiac arrest is limited and uncertain.
Verbatim wording from the response “WMAS acknowledges that, based on the JRCALC cardiac arrest guidance, where opioid toxicity is considered the likely cause, the cumulative Naloxone Hydrochloride dose required would exceed the stock carried on a single ambulance, and a second ambulance. However, WMAS does not consider this to represent a realistic or operationally appropriate benchmark against which the WMAS Drug Load List should be assessed.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current load-list quantity of 10 naloxone ampoules per ambulance is considered appropriate for respiratory arrest or respiratory depression.
Verbatim wording from the response “WMAS has undertaken formal clinical review of this issue. An initial review of Naloxone Hydrochloride quantities was completed in May 2025 by the WMAS Consultant Paramedic for Emergency Care, followed by a further review in September 2025 by the senior clinical team. The latter specifically considering the cardiac arrest guidance where opioid overdose is suspected. The consensus from the latest review was that the current Naloxone Hydrochloride quantities carried on the WMAS Load List were appropriate.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation JRCALC and Class Publishing are responsible for resolving the app’s format, navigation and usability issues.
Verbatim wording from the response “The Naloxone Hydrochloride guidance within the JRCALC PLUS App is authored by JRCALC and digitally formatted and published by Class Publishing. WMAS do not have the ability to customise the format, layout, or navigation structure of the JRCALC PLUS App. This includes the location of drugs, the tabs used to access them, and the presentation of reference tables. These design and structural elements are determined centrally by JRCALC and Class Publishing and are applied consistently across all subscribing ambulance services.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Full adherence to repeated naloxone dosing during cardiac arrest is impracticable because of task saturation and competing life-saving interventions.
Verbatim wording from the response “WMAS recognises that, in the context of an active cardiac arrest, achieving this dosing regimen is not realistically achievable. Cardiac arrest management requires the simultaneous delivery of multiple time-critical interventions, including high-quality CPR, airway management, ventilation, rhythm recognition, defibrillation where appropriate, vascular access, drug preparation and administration, and team leadership. Unless multiple additional clinicians are present with a designated role focused exclusively on the repeated preparation, checking, and administration of Naloxone Hydrochloride, compliance with this aspect of the guideline is not practicable during resuscitation.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation JRCALC and Class Publishing are responsible for resolving concerns about the naloxone cardiac-arrest guideline.
Verbatim wording from the response “Overall, this issue reflects a disconnect between guideline intent and what is operationally achievable during cardiac arrest resuscitation, rather than an unreasonable failure to follow guidance. WMAS considers that, in this context, the guideline may not be fully realistic for frontline application and should be interpreted pragmatically, with patient-centred prioritisation of core life-saving interventions. The WMAS Medical Director has raised these points with JRCALC, and it is our understanding that the Naloxone Hydrochloride guidance will be reviewed.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increasing naloxone stock would impose significant logistical and financial burdens disproportionate to its limited and uncertain cardiac-arrest benefit.
Verbatim wording from the response “There are also practical considerations related to medicine supply resilience. Naloxone Hydrochloride has previously been subject to national supply constraints. Increasing carriage to 25 ampoules per ambulance, alongside maintaining sufficient reserve stock to support fleet-wide replenishment, would present a significant logistical and financial burden. When weighed against the limited and uncertain benefit of Naloxone Hydrochloride in cardiac arrest, this does not represent a proportionate risk-benefit or cost-benefit intervention.” Source location Response from West Midlands Ambulance Service
Open published response
16 Sep 2025 Mohammed Ismail KHAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of mandatory and comprehensive paramedic training in obstetric emergencies View source Failure to adhere to clinical guidance for assessing and managing delayed breech birth View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mohammed Ismail KHAN · 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
Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development .
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course .
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted .
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course.
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide continuing professional development through maternity roadshows, themed maternity learning and expert-led obstetric-emergency simulation.
Verbatim wording from the response “The Trust has put multiple measures in place to provide Continual Professional Development (CPD) to our staff including well attended “Maternity Roadshows” led by ████████ in September and October 2023 where a Victoria mannequin was utilised to simulate births and obstetric emergencies supported by the Maternity Champions. In September 2023, we held a themed Maternity Month where Maternity Roadshows were held with 9 expert guest speakers. On October 9th 2024, one of the guest speakers was a Breech Specialist Midwife from Birmingham Women’s Hospital who demonstrated a live breech birth simulation using a Victoria mannequin.” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regulated obstetric-emergency and breech-birth training through the AAP and Graduate Paramedic Induction programmes.
Verbatim wording from the response “Training for obstetric emergencies is provided within The Level 4, 5 and 6 Associate Ambulance Practitioner (AAP) Programme which is a regulated training programme for all student paramedics on the apprenticeship pathway employed by WMAS.” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver practical breech-birth simulation sessions using Victoria mannequins and other maternity training equipment, updated following the new guidance.
Verbatim wording from the response “The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive training experiences for handling all obstetric emergencies including breech birth.” Source location Response from Association of Ambulance Chief Executives
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 Include obstetric emergencies, including breech birth, in mandatory face-to-face refresher training for all ambulance clinicians during 2026–2027.
Verbatim wording from the response “West Midlands Ambulance Service clinicians partake in yearly refresher mandatory training both face to face in a classroom and online. Prior to this PFD being issued discussions and planning had taken place to include obstetric emergencies including breech birth within next year’s 2026/27 face to face mandatory training.” Source location Response from Association of Ambulance Chief Executives
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 Relaunch the e-PROMPT obstetric-emergency course and make it available for clinicians to complete.
Verbatim wording from the response “Response
At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in national guidance so our clinicians could not complete this additional training. This was not due to resourcing. The course has now been relaunched and on 16th October 2025 our Education and Training Department advertised this in our Weekly Briefing and clinicians can now complete this.” Source location Response from Association of Ambulance Chief Executives
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 Purchase and deploy five Victoria birthing mannequins for realistic obstetric-emergency simulation training.
Verbatim wording from the response “The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive training experiences for handling all obstetric emergencies including breech birth.” Source location Response from Association of Ambulance Chief Executives
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 Update the paramedic breech birth algorithm with manoeuvre guidance, illustrations, videos and step-by-step advice.
Verbatim wording from the response “It is noted that Mohammed was born using the Lovesset’s manoeuvre. At the time of the incident, the paramedic breech birth algorithm did not provide sufficient detail on how to perform the full manoeuvre. The guidance has since been updated to make it clear and allow paramedics to use this manoeuvre safely and effectively when needed.” Source location Response from Association of Ambulance Chief Executives
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 Require ambulance clinicians to review the updated JRCALC breech-delivery guidance during Clinical Supervision shifts.
Verbatim wording from the response “A Clinical Supervision shift (CS1) is mandatory for all ambulance clinicians and during this shift planned in the year 2024/25, staff were informed to review the new JRCALC guidance on breech delivery.” Source location Response from Association of Ambulance Chief Executives
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 Relevant obstetric content in broader refresher training and CPD, alongside accessible JRCALC guidance, is considered sufficient without a standalone mandatory module.
Verbatim wording from the response “Operational staff have access to the JRCALC clinical guidelines, which provide evidence-based guidance for the management of obstetric emergencies. These guidelines are readily available and regularly updated.” Source location Response from Association of Ambulance Chief Executives
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 The e-PROMPT course was unavailable because guidance updates paused it, not because resourcing prevented clinicians from completing it.
Verbatim wording from the response “Response
At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in national guidance so our clinicians could not complete this additional training. This was not due to resourcing. The course has now been relaunched and on 16th October 2025 our Education and Training Department advertised this in our Weekly Briefing and clinicians can now complete this.” Source location Response from Association of Ambulance Chief Executives
Open published response
6 Jun 2024 Robert John Fray · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of the automated duplicate checker to identify repeat calls when the patient changes location View source Failure to prompt call assessors to consider repeated 999 calls over time when assessing urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert John Fray · 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
Robert John Fray became unwell with suspected sepsis during a dialysis session on 4 April 2022, and ambulance delays and emergency department failures meant he remained untreated for many hours. He developed multi-organ failure after sepsis and a stroke and died on 9 April 2022. The principal concerns were that repeated 999 calls did not trigger consideration of a more urgent response and that the duplicate-call system failed to identify a further call when his location changed.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the automated duplicate checker to identify repeat calls when the patient changes location
Wider context from the report “1. A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls.
2. Linked, the automated ‘duplicate checker’ is based on checking location within a 250-meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prompt call assessors to consider repeated 999 calls over time when assessing urgency
Wider context from the report “1. A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls.
2. Linked, the automated ‘duplicate checker’ is based on checking location within a 250-meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters.
” 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 Implement a call-taking protocol requiring clinical review when three or more repeat calls are identified.
Verbatim wording from the response “The Trust acknowledges the concern raised in Regulation 28 Report to Prevent Future Deaths, relating to the management of repeat calls. The Trust details the actions to identify duplicate, or repeat calls, in response to concern 2 below. In response to your first recommendation, the Trust will implement a change in call taking protocol that requires a clinical review of a patient’s condition where three or more repeat calls are identified. This will support an immediate review of the patient’s call history and presenting symptoms.” Source location 2024-0307 Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an alternative duplicate-call detection method using patient and caller demographic details beyond location-based matching.
Verbatim wording from the response “The Trust is sorry that in the case of Mr Fray neither method described correctly identified the final call to his home address as a duplicate call. The Trust therefore agrees with the recommendation within the Regulation 28 Report to Prevent Future Deaths to implement an alternative method for detection based upon the patient's personal demographics.” Source location 2024-0307 Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A higher response category would not have been achieved because the patient was reported conscious and breathing regularly.
Verbatim wording from the response “As described in the circumstances relating to the Regulation 28 Report to Prevent Future Deaths, during the fifth 999 call that originated from a neighbour, Mr Fray received a further triage of his symptoms requiring a category 2 response. A higher response category would not have been achieved, due to Mr Fray being reported as conscious and breathing regularly. This call would therefore not have changed the priority of the existing response.” Source location 2024-0307 Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Established protocols treat repeat calls as requiring full retriage only when the patient's condition has changed or worsened.
Verbatim wording from the response “The Trust answers, triages and processes 999 calls in-line with established call taking protocols that detail the required actions for managing duplicate or repeat calls. Most duplicate calls received are not because a patient’s condition has changed, they are because a caller is seeking an estimated arrival time. These calls are not routinely retriaged as it has been confirmed that there is no change in the patients presenting condition which means that the response category will not differ from that originally established. All duplicate calls from patients or callers, where it is confirmed the condition of the patient has changed or worsened will receive a full NHS Pathways triage. If the” Source location 2024-0307 Response from West Midlands Ambulance Service
Open published response
16 Feb 2024 Rosie Catherine YOUNG · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to ensure that employees transporting patients detained under the MHA are familiar with and trained to apply the MHA Transportation Policy View source Failure to ensure that employees apply other MHA policies and procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rosie Catherine YOUNG · 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
Rosie Catherine YOUNG died on 8 November 2021 after sustaining a traumatic brain injury when she stepped from the rear door of a moving ambulance while being transported to a psychiatric unit. The inquest identified concerns about failures to record and communicate her previous incidents of jumping from moving vehicles, inadequate risk assessment and transport arrangements, and insufficient staff awareness and training regarding the Mental Health Act Transportation Policy.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that employees transporting patients detained under the MHA are familiar with and trained to apply the MHA Transportation Policy
Wider context from the report “3) It seems that your Trust appeared at the time of these events to have had no system in place to ensure that those of your employees who dealt with the transportation of patients detained under the MHA were familiar with and trained to apply the provisions of the version of this Policy which was in force at the time . It is of concern therefore that if that remains the case, not only in relation to the MHA Transportation Policy, but in relation to other policies and procedures under the MHA, circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that employees apply other MHA policies and procedures
Wider context from the report “3) It seems that your Trust appeared at the time of these events to have had no system in place to ensure that those of your employees who dealt with the transportation of patients detained under the MHA were familiar with and trained to apply the provisions of the version of this Policy which was in force at the time. It is of concern therefore that if that remains the case, not only in relation to the MHA Transportation Policy, but in relation to other policies and procedures under the MHA , circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” 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 Produce an audit to assess compliance with the Mental Health Act Transportation Policy after completing the other actions.
Verbatim wording from the response “5. Following all the above actions an audit will be produced to ensure compliance with the Mental Health Act Transportation Policy.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review initial training packages for new patient-facing staff to ensure appropriate Mental Health Act transportation content.
Verbatim wording from the response “3. The Trust will review its initial training packages for all new staff in patient facing roles to ensure that appropriate content is provided to support their knowledge and practice in respect of patients transported under the Mental Health Act.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate further education through weekly briefings and clinical publications on policy requirements and staff roles supporting this patient group.
Verbatim wording from the response “3. Further education will be disseminated to staff through the weekly briefing and clinical times publications to expand upon the requirements of the Mental Health Act Transportation Policy and the role of WMAS staff in supporting this patient group.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and disseminate a clinical notice highlighting Mental Health Act Transportation Policy requirements to staff.
Verbatim wording from the response “2. A clinical notice has been produced and disseminated through internal communications channels to highlight the requirements of the Trust’s Mental Health Act Transportation Policy to its staff” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Mental Health Act Transportation Policy, then share the revised live document with multi-agency partners.
Verbatim wording from the response “1. A piece of work has already been undertaken to review the Trust’s Mental Health Act Transportation Policy, in consultation with multi-agency partners, in order to update this document to ensure that lessons learnt in this case have been captured. This revised document is now live and has been shared with multi-agency partners across the West Midlands.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate specific Mental Health Act Transportation training, including risk assessment, into the 2024/25 statutory and mandatory eLearning workbook.
Verbatim wording from the response “1. Additional specific training has been incorporated into the Trust’s Statutory and Mandatory eLearning workbook for 24/25 in respect of Mental Health Act Transportation, including in respect of the risk assessment.” Source location Response from West Midlands Ambulance Service
Open published response
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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 West Midlands Ambulance Service University NHS Foundation Trust; 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 Review Trust referral practices to ensure appropriate fitness-to-practise referrals are made.
Verbatim wording from the response “Response
The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver an in-person CPD event covering ECG signs and recognition.
Verbatim wording from the response “June 2023” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide remedial ECG and acute coronary syndrome training to both clinicians through training school.
Verbatim wording from the response “Both the clinicians are booked to attend training school for remedial training on the 1 December 2023. In addition to this ████████ will be meeting with the Trust’s Consultant Paramedic who is the Head of Clinical Care, ████████ to review and reflect on the ECG abnormalities as part of an additional self reflection request.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish ACS discharge-on-scene case learning and link staff to ACS educational resources.
Verbatim wording from the response “August 2023” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support a clinician’s attendance on a level-six ECG-in-practice university course.
Verbatim wording from the response “Since the incident ████████ has also requested to attend a level 6 university course to further her knowledge on ECG’s. ████████ has been approved and supported by WMAS to attend a level 6 ECG in practice course, commencing in January 2024.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
Verbatim wording from the response “• Evening training session on ECGs and Resus skills delivered” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ECG recognition and advanced life support sessions with Zoll Medical.
Verbatim wording from the response “February 2023” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
Verbatim wording from the response “• There was a CPD day at Erdington hub alongside the Research team to provide presentation on STEMI clinical times article on ACS and the new JRCALC update, including the ambulance quality indicators and time from 999 call to inflation of a balloon in a specialist coronary catheter” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
Verbatim wording from the response “September 2023” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Microsoft Teams channel for publishing ECG case studies and facilitating clinical discussion.
Verbatim wording from the response “• Microsoft teams channel set up for regular publication of ECG case studies and to allow for discussion” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue staff education articles on using ECG monitors’ automatic diagnostic function.
Verbatim wording from the response “As part of the Trusts ongoing education and training for staff we have undertaken a range of initiatives to improve the understanding of ECGs and the auto diagnostic function of ECGs.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Q-wave changes and AVR deflection are included in training but are not significant features of the high-level ECG competency described.
Verbatim wording from the response “Response
Q wave changes and AVR deflection does feature in our training but is not a significant feature, as this is high level ECG competency. The ECG auto diagnostic did identify an abnormal ECG and this should have been acted upon.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Internal paramedic training includes qualitative ECG assessments, and university course provision is regularly reviewed against Trust and HCPC requirements.
Verbatim wording from the response “Response
In addition to the training evidenced in response to concern 3 & 4, the Trust can confirm that all internally delivered initial paramedic training includes qualitative ECG assessments. ████████ undertook an ECG assessment on 4 August 2020 as part of her Technician training (Appendix 11) which tested her knowledge on ECG interpretation, she passed this assessment with a score of 92.5%. This test covered Q waves and ST elevation.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An employer referral was not considered necessary under HCPC guidance following the serious incident investigation.
Verbatim wording from the response “Response
The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.” Source location Response from West Midlands Ambulance Service
Open published response
9 May 2023 Sandra Dianne Finch · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 3 Lack of a prioritisation system for category 3 ambulance call assessments View source Lack of time limits for category 3 ambulance call assessments View source Failure of ambulance categorisation pathways to allow movement away from rigid categories View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sandra Dianne Finch · 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
Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a prioritisation system for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system , will lead to further deaths resulting from delays.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of time limits for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place , and no prioritisation system, will lead to further deaths resulting from delays.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance categorisation pathways to allow movement away from rigid categories
Wider context from the report “1. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path . This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly .
” 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 Prioritise category 3 and 4 clinical-assessment callbacks in incident-category time order, targeting contact within 60 minutes.
Verbatim wording from the response “The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a clinical validation process that triages category 3 and 4 incidents, routes patients to appropriate outcomes, and increases ambulance response categories where clinically indicated.
Verbatim wording from the response “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, led to the clinical validation team becoming a substantiated process within the Trust.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight patients waiting over 120 minutes, and every subsequent 120 minutes, for further clinical-navigator risk assessment.
Verbatim wording from the response “The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have senior clinical navigators risk-assess patients awaiting clinical assessment, arrange ambulance dispatch for unsuitable patients, and upgrade incidents when indicated.
Verbatim wording from the response “All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical validation, prioritisation, risk assessment and escalation arrangements are considered sufficient to manage category 3 and 4 delays safely.
Verbatim wording from the response “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, led to the clinical validation team becoming a substantiated process within the Trust.” Source location Response from West Midlands Ambulance Service
Open published response
19 Apr 2023 DAVID ERNEST MASON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
DAVID ERNEST MASON · 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
David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress . Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that , as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy , to prevent the development of an acute adrenal crisis.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress .
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis .
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason 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 Communicate updated adrenal-crisis and steroid-dependent-patient guidance to staff through clinical times and clinical notices.
Verbatim wording from the response “Response
In 2017 there was an update in the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance emphasising the increased usage of Hydrocortisone for patients with adrenal crisis, including a further note stating if in doubt administer Hydrocortisone. This was communicated to all staff through the clinical times edition 30. The clinical times is an internal quarterly briefing which provides all staff with new or updated clinical guidance.” Source location Response from West Midlands Ambulance Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.
Verbatim wording from the response “Response
Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).” Source location Response from West Midlands Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinicians with access to JRCALC guidance through individual licenses and the JRCALC Plus app.
Verbatim wording from the response “All WMAS clinicians are given access to the JRCALC guidelines through individual licenses for the JRCALC Plus app. Staff are also provided a Trust personal issue Ipad and the app can be accessed through this device, or there is the option for the app to be also downloaded on other devices such as personal smart phones if they so choose so. This allows clinicians to access the guidelines whilst at the patient side.” Source location Response from West Midlands Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an in-depth clinical-times article to improve clinicians’ knowledge of adrenal insufficiency and replacement steroid therapy.
Verbatim wording from the response “Response
Following review of the serious incident investigation and receipt of the PFD we agree a recommendation should have been made to raise awareness and improve clinicians knowledge of adrenal insufficiency and the importance of considering administering replacement steroid therapy. Therefore we have reemphasised the care of the steroid dependant patient with an in depth article with appropriate links for further reading and education, publishing the below in the clinical times on the 12th of May 2023.” Source location Response from West Midlands Ambulance Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate relevant external clinical guidance, including steroid emergency-card guidance, through weekly staff briefings.
Verbatim wording from the response “As well as the above a number of articles have been run within the WMAS weekly briefing. The weekly briefing which is emailed to all WMAS employees provides all the latest information about WMAS and any changes to guidance that have been made by external bodies in relation to clinical practice that must be considered. An example of such is below:” Source location Response from West Midlands Ambulance Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation WMAS cannot change the nationally required NHS Pathways triage system used to assess 999 calls.
Verbatim wording from the response “Response
Calls to 999 are assessed in accordance with the Department of Health National Guidelines using a process called NHS Pathways (NHSP).” Source location Response from West Midlands Ambulance Service
Open published response
18 Jan 2021 Mrs Lynn Hadley · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of user knowledge of oxygen-cylinder ignition mechanisms and their ramifications View source Risk of ignition within oxygen-cylinder valve components View source Failure to follow the safe valve-opening sequence for oxygen regulators View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Lynn Hadley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 13 April 2020, paramedics attended Mrs Lynn Hadley at home for COVID-19-type symptoms and began administering oxygen. The oxygen cylinder sparked and caught fire, and despite efforts by family members and paramedics, Mrs Hadley could not be removed from the house and died from fatal burn injuries. The concerns included possible ignition caused by adiabatic compression or particle impact when the oxygen regulator was opened, limited awareness of these risks among equipment users, and other reported cases of ignition involving oxygen-cylinder valve components.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of user knowledge of oxygen-cylinder ignition mechanisms and their ramifications
Wider context from the report “4. Evidence from the Fire Investigation Officer, confirmed that there was little if any knowledge of either adiabatic compression or particle impact and the ramifications of such an event when opening a cylinder incorrectly by those responsible for using the equipment .
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of ignition within oxygen-cylinder valve components
Wider context from the report “5. Evidence from the MHRA confirmed that they are aware of four cases of ignition within valve components of oxygen cylinders leading to fire since 2011 including this incident . The valve manufacturer VTI, Germany has subsequently reported nine cases of ignition . VTI are also examining a further 20 regulators. At present no defects have been found.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the safe valve-opening sequence for oxygen regulators
Wider context from the report “2. Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition .
3. Evidence from the paramedic confirmed that she opened the patient valve first before opening the on/off valve, thus increasing the chance of the reported phenomena occurring .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make all frontline staff aware of medical-gas-cylinder assembly and disassembly requirements, adiabatic compression, and particle-impact risks.
Verbatim wording from the response “Response:
WMAS took immediate action as detailed during the Inquest. All frontline WMAS staff were swiftly made aware of the specific requirements for assembly/disassembly of all medical gas cylinders, awareness of adiabatic compression and particle impact, and furthermore a great deal of input went into sharing lessons learned widely throughout partner organisations. The table below provides a summary/timeline of action taken.” Source location 2021-0346-Response-from-West-Midlands-Ambulance-Service_Published
Open published response
14 Dec 2020 Elsie Yvonne Taylor · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 9 Inaccurate wording in discharge notices about GP referral as an alternative to hospital admission View source Failure to record hospital advice and the person's understanding of that advice View source Failure to contact the GP or a family member when a patient living alone requires follow-up View source Failure to provide information about symptoms indicating deterioration View source Failure to include clinically relevant information in discharge notices View source Failure to leave information recording the admission decision and paramedic advice View source Failure to record a decision to decline hospital admission in the EPR View source Failure to obtain a disclaimer when hospital admission is declined View source Failure to document the outcome of the consultation View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elsie Yvonne Taylor · 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
Elsie Yvonne Taylor, aged 68, fell at home on 15 September 2020, sustained rib fractures and a pneumothorax, and died later the same day after deteriorating in hospital. Concerns included incomplete recording of her reported decision to decline hospital admission and the advice given, lack of information about the consultation and deterioration symptoms, and no attempt to contact her GP or family despite her living alone.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate wording in discharge notices about GP referral as an alternative to hospital admission
Wider context from the report “(5) The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission ;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record hospital advice and the person's understanding of that advice
Wider context from the report “(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the GP or a family member when a patient living alone requires follow-up
Wider context from the report “(6) The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR).
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide information about symptoms indicating deterioration
Wider context from the report “(3) There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased ;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include clinically relevant information in discharge notices
Wider context from the report “(5) The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to leave information recording the admission decision and paramedic advice
Wider context from the report “(3) There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics . The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a decision to decline hospital admission in the EPR
Wider context from the report “(1) The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a disclaimer when hospital admission is declined
Wider context from the report “(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer ;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the outcome of the consultation
Wider context from the report “(4) There was no note left by the attending paramedic crew detailing the outcome of the consultation ;
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
Verbatim wording from the response “Response
During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts’ expected standard of completing and checking documentation.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge form advised contacting or attending the GP; it did not indicate that the patient had been referred.
Verbatim wording from the response “Response
The box ticked on the discharge form states that the patient had been advised to contact or attend her GP practice. If a referral had been made on behalf of the patient one of the boxes at the top of the form would have been ticked.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A discharge sheet provided safety-netting information, so it was not correct that no relevant information or consultation outcome was left.
Verbatim wording from the response “Response
A discharge sheet was left with the patient, which detailed that the patient was to contact the GP or in the case of an emergency to call 999/111. The paramedic has confirmed that there was no family present but there was neighbour in attendance throughout the whole consultation. The neighbour was shown the bruise on the patient ribs and she informed the crew that she would stay with the patient for some time to keep an eye on her.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
Open published response
31 Jan 2020 Ashley WALKER · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 3 Unavailability of an effective antidote on ambulances View source Toxicity of the substance as a recognised method of suicide View source Failure to distinguish ingestion from spillage in communication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ashley WALKER · 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
Ashley WALKER ingested a substance and was treated by an ambulance crew, who left after being told the scene was hazardous; he was left unattended for 45 minutes and was not breathing when extricated. The concerns included a communication error about the substance involved and the absence of an effective antidote on the ambulance.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an effective antidote on ambulances
Wider context from the report “(2) ████████ toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Toxicity of the substance as a recognised method of suicide
Wider context from the report “(2) ████████ toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish ingestion from spillage in communication
Wider context from the report “(1) It is apparent that a communication error confused the ingestion of ████████ with a spillage of ████████
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise nationally with the NARU clinical subgroup the proposal to make methylene blue availability standard practice.
Verbatim wording from the response “Response
We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.” Source location Response-from-West-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove WISER from frontline work devices and restrict its use to trained incident and hazardous-area officers.
Verbatim wording from the response “Response
Following this incident we have instructed all of our staff to remove the WISER (Wireless Information System for Emergency Responders) App from all work mobile phones and tablets. The App will now only be used following triaging by Tactical Incident Commanders (TICs), the National Inter-Agency Liaison Officer (NILO) and team leaders in our Hazardous Area Response Team (HART). This is to ensure the risk of harm to both our patients and staff is reduced and to mitigate confusion at scene, as crews on scene will only be able to access advice from trained officers.” Source location Response-from-West-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether HART paramedics can carry and administer methylene blue for sodium nitrate ingestion cases.
Verbatim wording from the response “Response
We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.” Source location Response-from-West-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce guidance for officers distinguishing clinical management of individual chemical ingestion from chemical spills.
Verbatim wording from the response “As a Trust we have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents which highlight the clinical management differences between individual ingestion and chemical spills for all of our Officers.” Source location Response-from-West-Midlands-Ambulance-Service
Open published response
18 Nov 2019 Emma Jayne Langley · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to clearly communicate that non-conveyance constitutes rejection of medical advice to distressed patients or their families 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
Emma Jayne Langley · 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
Emma Jayne Langley developed headache and vomiting after being diagnosed with an ear infection, and an ambulance attended her home. She was not taken to hospital, later collapsed, and was confirmed deceased; post-mortem tests identified Streptococcus pneumoniae and the medical cause of death was acute meningitis. The principal concern was that the process for recording non-conveyance did not adequately communicate to the patient or family that they were rejecting medical advice to admit her to hospital.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate that non-conveyance constitutes rejection of medical advice to distressed patients or their families
Wider context from the report “The deceased/her family were keen for her to be admitted to hospital. The paramedic asked the deceased’s partner to sign the ‘non-conveyance’ statement on his EPR tablet after summarising a 1 hour 45 minute attendance. The rejection of medical advice was diluted by other details. The deceased’s partner stated he did not appreciate what he was signing. He was distressed and emotional and the room had been busy with family members, the paramedics and his ill partner.
In my judgment, the facts of this case demonstrate the current system of signing a screen on a tablet after a generic summary, does not adequately amplify to a patient/their family (who might be distressed and emotional) they are rejecting medical advice to be admitted to hospital.
” Open source report
15 Sep 2017 Reginald Dixon · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to accurately triage emergency calls View source Insufficient resources for timely emergency response View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Reginald Dixon · 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 Dixon, a 70-year-old man, suffered an unwitnessed fall downstairs on 26 June 2017, sustaining multiple injuries including a severe head injury. He was taken to hospital after a 57-minute delay from the original emergency call and died the same day. Concerns included the incorrect triage of a later call and insufficient ambulance resources contributing to delays in response times.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately triage emergency calls
Wider context from the report “1. Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level 3 . The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time.
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for timely emergency response
Wider context from the report “2. Evidence also emerged during the inquest that there were insufficient resources available and average response times of 29 minutes . This delay posed a risk to patients .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to the Clinical Commissioning Group about current resourcing provision and include the Preventing Future Death report.
Verbatim wording from the response “Response - The Trusts Director of Clinical Commissioning and Service Development/Executive Nurse has personally written to the Clinical Commissioning Group over the current resourcing provision and has included within that letter the Preventing Future Death report.” Source location 2017-0214-Response-by-West-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver further education and refresher training on head injuries through the NHS Pathways update.
Verbatim wording from the response “Following this serious incident WMAS have included further education and refresher training around head injuries during the NHS Pathways update due to take place in October/November.” Source location 2017-0214-Response-by-West-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is unclear whether the call was incorrectly categorised because the caller’s answers may not have supported a Category 2 response.
Verbatim wording from the response “Response - The second 999 call had failed the audit completed against the Pathway system. The audit identified that the call assessor did not fully establish during the call the level of consciousness of the patient, further probing was required, due to the lack of probing on the call it is unclear whether the category 3 response which was generated was appropriate.” Source location 2017-0214-Response-by-West-Midlands-Ambulance-Service
Open published response
Concerns raised 3 Failure of triage to undertake further and detailed assessment of spinal injury risk View source Delays in diagnosing suspected spinal cord injury View source Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment 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 Frederick White · 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 Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of triage to undertake further and detailed assessment of spinal injury risk
Wider context from the report “(2) Evidence emerging from the inquest suggested that the initial failure to immobilise the patient continued when he arrived at Hospital and the triage process failed to adequately assess the risk again . It appears the triage process is heavily reliant upon the handover from the paramedic crew without further and detailed assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosing suspected spinal cord injury
Wider context from the report “(3) It wasn't until five hours after the initial fall that a suspected spinal cord injury was diagnosed .
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment
Wider context from the report “(1) Spinal injuries are relatively uncommon but have the potential to cause significant morbidity and mortality if not managed effectively. Mr White was an elderly patient who was at risk of falling during the course of the inquest evidence emerged showing that he had sustained a traumatic injury of significant blunt force trauma. He also gave a description of feelings of numbness and lack of sensation in his legs and there was also a drop in blood pressure, which should have prompted a conservative approach in treating the patient by applying immobilisation on suspicion of spinal cord injury during his initial examination and assessment .
” Open source report
24 Sep 2014 Caroling Carter Crowther · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to permit paramedics to compel psychiatric patients to attend hospital in the absence of police View source Failure to provide clear and consistent policy on compelling psychiatric patients to attend hospital 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
Caroling Carter Crowther · 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
Mrs Crowther, a patient detained under Section 3 of the Mental Health Act, became physically unwell and died after paramedics declined to take her to hospital despite differing views about her capacity and need for treatment. The concerns included conflicting accounts of whether Trust policy prevented paramedics from compelling a psychiatric patient to attend hospital, including without police presence.
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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to permit paramedics to compel psychiatric patients to attend hospital in the absence of police
Wider context from the report “(1) The Paramedic who gave evidence expressed a view that it was "Trust Policy" that a
psychiatric patient whether or not they had capacity should not be compelled to go to
hospital even when it was universally agreed that she was grievously ill.
(2) The Paramedic concerned indicated that without the presence of the police to
physically coerce the patient, Paramedics within the Trust had been told that they should
not become involved in physical coercion .
(3) The Area Support Officer who gave evidence flatly contradicted the Paramedic and
said that it was NOT Trust policy to act in this way and that Paramedics could and
should (in appropriate cases) compel a patient in need to attend hospital
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent policy on compelling psychiatric patients to attend hospital
Wider context from the report “(1) The Paramedic who gave evidence expressed a view that it was "Trust Policy" that a
psychiatric patient whether or not they had capacity should not be compelled to go to
hospital even when it was universally agreed that she was grievously ill.
(2) The Paramedic concerned indicated that without the presence of the police to
physically coerce the patient, Paramedics within the Trust had been told that they should
not become involved in physical coercion.
(3) The Area Support Officer who gave evidence flatly contradicted the Paramedic and
said that it was NOT Trust policy to act in this way and that Paramedics could and
should (in appropriate cases) compel a patient in need to attend hospital
” Open source report
10 Jan 2014 Mary WALDRON · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 9 Failure of nursing home staff to take appropriate action when aware of low blood pressure View source Inability of the nursing home to address future risks relating to a nurse's training View source Lack of clarity regarding the status of the Care Quality Commission investigation View source Failure of nursing home staff to recognise acutely unwell residents View source Failure of nursing home managers to take action to prevent recurrence View source Failure of nursing home managers to undertake effective incident investigations View source Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times View source Inaccurate reporting by nursing home managers to the Care Quality Commission View source Lack of ongoing training in recognition and treatment of acutely unwell residents 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.
×
AI-generated summary
Mary WALDRON · 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
Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.
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× 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home staff to take appropriate action when aware of low blood pressure
Wider context from the report “(2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure ;
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of the nursing home to address future risks relating to a nurse's training
Wider context from the report “(7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary's nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse ;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity regarding the status of the Care Quality Commission investigation
Wider context from the report “(6) lack of clarity as to the investigation that is to be undertaken by the CQC . The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home staff to recognise acutely unwell residents
Wider context from the report “(1) failure of the nursing home staff to recognise an acutely unwell resident ;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home managers to take action to prevent recurrence
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home managers to undertake effective incident investigations
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” 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 West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times
Wider context from the report “(8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times , with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver . Direct visualisation of a satellite navigation console by the non-driving paramedic could address this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate reporting by nursing home managers to the Care Quality Commission
Wider context from the report “(5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed , when evidence given at the inquest was that this was not the case ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Ambulance Service University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing training in recognition and treatment of acutely unwell residents
Wider context from the report “(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents ; with reliance solely on initial nursing training ;
” Open source report
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Addressed to West Midlands Ambulance Service NHS Trust, now represented here by West Midlands Ambulance Service University NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations