27 Apr 2026 Christine Joan Clegg · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck 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.
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AI-generated summary
Christine Joan Clegg · 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
Christine Joan Clegg died at Hull Royal Infirmary after an unwitnessed fall at her care home, in which she sustained a traumatic brain injury and later deteriorated. The report raises concern that inaccurate information given to NHS 111 led to a minor-wounds pathway being followed instead of the head-injury pathway, resulting in basic first-aid advice without clinical input. It also concerns the availability of the minor-wounds script for injuries above the neck, which may lead to a non-clinical outcome for head injuries.
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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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
Wider context from the report “(1) The NHS 111 script for scratches grazes or minor wounds is available for head injuries but can lead to a non clinical outcome and basic first aid advice being given. The fact is, however, either a scratch, graze or nick above the neck indicates that either has been a head injury of some degree or other and so the script which should correctly be followed is the head injury pathway. If injuries above the neck were excluded from the scratches grazes and nicks pathway then the possibility of basic first aid advice being given is eliminated as all head injury answered result in clinician advice being sought.
” Open source report
23 Dec 2025 Colin Richard BROWN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 3 Failure to routinely check for patients' choking risks during handovers View source Delays in making electronic patient information accessible to receiving hospital staff View source Failure to transport patients' care plans with them to hospital 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
Colin Richard BROWN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.
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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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check for patients' choking risks during handovers
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers . It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves , as was the case here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in making electronic patient information accessible to receiving hospital staff
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown . Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers. It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves, as was the case here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transport patients' care plans with them to hospital
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital . There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers. It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves, as was the case here.
” 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 Issue a clinical alert reinforcing explicit handover of known high-impact risks and documentation of verbal handover content.
Verbatim wording from the response “1. Clinical emphasis within handover guidance: YAS will issue a clinical alert to all staff to reinforce that known high-risk features not directly related to the presenting complaint (for example swallowing/choking risk, severe cognitive impairment, or behavioural risk) should be considered for explicit verbal handover where omission could reasonably result in harm and that clinicians document the contents of the verbal handover.” Source location Response from Yorkshire Ambulance Service NHS Trust
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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 case learning into the monthly Patient Safety Bulletin and support local educational sessions for clinical staff.
Verbatim wording from the response “3. Targeted learning and awareness: Learning from this case will be incorporated into the monthly YAS Patient Safety Bulletin accessible to all clinical staff. These materials will also support local educational sessions (termed internally as ‘investment days’) and will emphasise professional judgement, advocating for the continued use of structured, succinct and clinically pertinent handover conversations.” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore through digital governance whether electronic patient records can present swallowing or choking risks more rapidly and consistently.
Verbatim wording from the response “4. Electronic record development (subject to system constraints)
YAS will explore, through its established digital governance processes, whether existing EPR systems can more rapidly share swallowing or choking risk in a consistent location, recognising that any such development is dependent on” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update handover protocols where appropriate to reflect contemporary practice and learning from the case.
Verbatim wording from the response “2. Review of handover protocols: YAS will review its handover protocols and update where appropriate to reflect contemporary practices and learning from this tragic case.” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ePR upload delay could not reasonably have influenced the choking event because the event occurred after the ePR became available to hospital staff.
Verbatim wording from the response “Delay between handover and ePR upload” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine verbalisation of choking risk for every patient is not operationally deliverable or proportionate and could cause information overload and missed pertinent details.
Verbatim wording from the response ““It is not feasible, nor clinically proportionate, for ambulance clinicians to identify and verbally communicate all potential secondary risks for every patient during every handover, particularly where these are longstanding conditions documented elsewhere and unrelated to the reason for conveyance. Adopting an approach such as this increases risk of key clinical information being missed and prolongs the handover process, meaning crews will be unable to respond to further emergencies. This is reflected in national guidance and contemporary literature advocating for structured, succinct handover. Structured handover therefore represents a balance between completeness and safety, aligned with human-factors principles and the avoidance of information overload.” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.
Verbatim wording from the response ““The information I have been provided shows the attending crew reported that Mr Brown did not disclose any requirement for a modified or soft diet to them, nor was any care plan or supporting documentation reported as existing or being provided, despite care notes within the bundle provided by HM Coroner stating Mr Brown required a modified diet. Furthermore, a collateral history was not obtainable as no carers or family members were at the scene. The ePR completed by the crew does include a past medical history entry noting previous swallowing difficulty. This reflects historical medical background obtained through them accessing the Summary Care Record for Mr Brown. This is part of routine history-taking and information gathering rather than identification of an active or clinically apparent risk at the time of ambulance assessment.” Source location Response from Yorkshire Ambulance Service NHS Trust
Open published response
28 Oct 2024 Susan Patricia SHIPLEY · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 4 Failure to undertake subsequent ‘fit to sit’ reassessments before onward ambulance transport View source Failure to complete relevant learning and resulting actions concerning ‘fit to sit’ practice View source Failure to document initial ‘fit to sit’ assessments View source Failure to make appropriate ‘fit to sit’ determinations for patients unable to weight bear View source See 1 more concern
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
Susan Patricia SHIPLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Patricia Shipley, who had critical limb ischaemia and previous amputations, fell from a hospital wheelchair while being transferred between hospitals on 28 January 2024 and fractured her right neck of femur. She underwent further amputations, developed pneumonia, and died in hospital on 4 February 2024. The principal concerns were the lack of documented and appropriate “fit to sit” assessments, the decision to transport her in a wheelchair despite her inability to weight bear, and the potential risk of death to others if similar issues recur.
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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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake subsequent ‘fit to sit’ reassessments before onward ambulance transport
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete relevant learning and resulting actions concerning ‘fit to sit’ practice
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document initial ‘fit to sit’ assessments
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate ‘fit to sit’ determinations for patients unable to weight bear
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” 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 Draft and progress a dedicated fit-to-sit policy through internal review and final clinical governance approval.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire 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 Conduct a Patient Safety Incident Investigation into the moving-and-handling care, including fit-to-sit decisions, handover, diversion, HALO involvement and specialist-hospital transport.
Verbatim wording from the response “Following the conclusion of your inquest, the complexities and potential for learning was discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive Medical Director. From this the commissioning of a full investigation into the care of Mrs Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” has been initiated, which focuses on identifying learning responses to improve our service to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to participate in this investigation.” Source location Response from Yorkshire 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 the approved fit-to-sit policy across YAS for use by all clinical staff.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire 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 Conduct a case-based safety discussion with clinicians from the first ambulance call and provide planned feedback to the HALO.
Verbatim wording from the response “Additionally, a case-based discussion has been held with the attending clinicians at the first ambulance call which led to the patient being transported to Scarborough Hospital. This was led by our Advanced Paramedic Clinical Lead and involved critically reflecting to enable points for consideration from a safety perspective to be highlighted. There is planned feedback for the HALO.” Source location Response from Yorkshire Ambulance Service
Open published response
1 Feb 2024 Peter STAJIC · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of paramedic training in identifying herald bleeds View source Lack of a protocol for paramedics to follow when identifying herald bleeds 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
Peter STAJIC · 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
Peter STAJIC died at Calderdale Royal Hospital on 27 February 2022 following a catastrophic haemorrhage after a carotid endarterectomy and subsequent wound infection. The report identifies missed opportunities to recognise a herald bleed and provide specialist vascular intervention, and raises concerns that paramedics had no training or protocol for identifying such a bleed.
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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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic training in identifying herald bleeds
Wider context from the report “Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26 February 2022 would not be expected to possess, the evidence to the Inquest was that they would not have had any training in identifying one , nor any protocol for them to follow.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for paramedics to follow when identifying herald bleeds
Wider context from the report “Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26 February 2022 would not be expected to possess, the evidence to the Inquest was that they would not have had any training in identifying one, nor any protocol for them to follow .
” Open source report
Concerns raised 2 Lack of guidance or protocols on when to take patients to hospital for thrombolysis View source Lack of guidance or protocols on when to stop resuscitation 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
Mark Bennett · 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
Mark Bennett died at Meadowhall Shopping Centre Sheffield on 14 April 2022 from a pulmonary embolism following a leg injury and immobility after a trip in the London Underground. During the inquest, concerns were raised that ambulance guidance was unclear about how long resuscitation should continue and when patients should be taken to hospital for possible thrombolysis, and that this might place future patients at risk.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or protocols on when to take patients to hospital for thrombolysis
Wider context from the report “5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis .
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or protocols on when to stop resuscitation
Wider context from the report “5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis.
” Open source report
Concerns raised 5 Failure of EPR records to accurately reflect information given to patients View source Failure to accurately transfer EPR information to patient information leaflets View source Failure to provide written follow-up of advice from virtual consultations View source Failure to assess patients’ understanding of advice during virtual consultations View source Failure to use a standard set of initial questions during clinical triage View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas Rawnsley · 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
Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of EPR records to accurately reflect information given to patients
Wider context from the report “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transfer EPR information to patient information leaflets
Wider context from the report “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written follow-up of advice from virtual consultations
Wider context from the report “(1) Primary care are undertaking more and more virtual consultations with patients and the advice that is provided is inherently more risky over the phone with GPs not being in a strong position to assess the patients understanding of the advice that has been given in the same way as they can when the patient is sitting in front of them in the practice. This advice is not followed up in writing and therefore it may be misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas, is having his care delivered by professional carers.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ understanding of advice during virtual consultations
Wider context from the report “(1) Primary care are undertaking more and more virtual consultations with patients and the advice that is provided is inherently more risky over the phone with GPs not being in a strong position to assess the patients understanding of the advice that has been given in the same way as they can when the patient is sitting in front of them in the practice. This advice is not followed up in writing and therefore it may be misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas, is having his care delivered by professional carers.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a standard set of initial questions during clinical triage
Wider context from the report “(2) There is a standard set of questions asked by the call handler on a 111 or 999 call which is not then replicated for clinicians who subsequently triage a patient . Without a standard set of initial questions asked it is entirely possible that clinicians will provide advice in isolation of other important matters . This could be as simple as current medications that the patient routinely takes or current diagnosis the patient has which impact upon the advice to be provided. This may lead to incomplete or worse, inappropriate advice being given to patients during a clinical triage.
” 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 Develop EPR tick-box indicators to record information left with patients.
Verbatim wording from the response “Additionally, and as an interim phase, the Trust will undertake the following:” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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 Embed Patient Information Leaflet contents fully within the EPR.
Verbatim wording from the response “The Trust’s future intention is to ensure that contents of the PIL are fully embedded in the EPR and, when technological developments allow, the Trust will have the facility to email this entire record to the patient and their primary care provider.” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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 Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.
Verbatim wording from the response “The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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 Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.
Verbatim wording from the response “Additionally, and as an interim phase, the Trust will undertake the following:” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
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 Re-audit care-plan documentation after the intervention.
Verbatim wording from the response “Additionally, and as an interim phase, the Trust will undertake the following:” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-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 Trust will not undertake patient-leaflet photo audits because of practical difficulties and concerns that advance notice would skew results.
Verbatim wording from the response “The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.” Source location 2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Open published response
Concerns raised 1 Failure to conduct a two-hour review for possible re-categorisation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Arthur William Jepson · 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
Arthur William Jepson suffered stomach pain and called 999; the ambulance arrived at 19.31 after the initial call was triaged as Category 5 and later reclassified as Category 3. The inquest identified that a required two-hour review to consider re-categorisation did not take place, raising concern that this could affect another case, although it was considered unlikely to have changed the outcome here.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a two-hour review for possible re-categorisation
Wider context from the report “During the inquest, evidence showed:-
1. that the pressure on resources was high that day.
2. that a review at the two hour point should have taken place to ascertain if the matter needed re categorisation.
3. Such a review didn’t happen.
4. Whilst the evidence at inquest was that this is unlikely to have changed the outcome in this case, it was a concern to me that it could be in another case.
” 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 Implement the ratified centralised Senior Clinical Advisor procedure for reviewing overdue incidents, making call-backs, and arranging reassessment or re-categorisation where needed.
Verbatim wording from the response “Your letter has prompted the Trust to refresh its approach to dealing with such matters and to build upon work already ongoing within the Emergency Operations Centres (“EOCs”) with improving its processes and procedures. As outlined within the letter from the Trust on 4 October 2019, there is work currently ongoing to create a centralised Senior Clinical Advisor standard operating procedure (“SOP”) and the current call-backs and comfort calls SOP has been identified as forming an integral part of this revised central SOP.” Source location 2019-0300-Response-by-Yorkshire-Ambulance-Service
Open published response
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant View source See 1 more concern
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
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” Open source report
Concerns raised 1 Ineffectiveness of the pathway for communicating information directly to the crisis team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Cyril Kiernan · 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
Christopher Cyril Kiernan, who had a history of depression, alcohol use and cannabis use, made threats to harm himself and had contact with emergency services during the night of 3–4 June 2017. He was later found hanging from a tree in nearby woodland. The principal concern was the ineffectiveness of the pathway for communicating information directly to the RDaSH Crisis Team, with the crisis team not being notified.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffectiveness of the pathway for communicating information directly to the crisis team
Wider context from the report “The ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team .
” Open source report
×
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 signposting and consent-based referral during the 999 call provide the available pathway to crisis services.
Verbatim wording from the response “Addressing your concern as to “the ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team”, I can state that there is a facility to:” Source location 2017-0304-Response-Yorkshire-Ambulance-Service-NHS-Trust
Open published response
Concerns raised 4 Absence of a safety-net system for failures to manually refresh and monitor the system View source Failure to adhere to ambulance dispatch and resource-review protocols View source Failure to escalate or allocate resources when time scales are breached View source Lack of knowledge, training and understanding of ambulance dispatch and resource-review protocols View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barry Stuart Hodges · 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
Barry Stuart Hodges, a 69-year-old man, collapsed with chest pains at a tennis club on 23 August 2016 and died after being transferred to hospital following cardiac arrest. The report identified failures to follow ambulance dispatch and resource-review protocols, insufficient safety-netting and apparent gaps in staff knowledge or training, with available resources not allocated and escalation not undertaken when timescales were breached.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a safety-net system for failures to manually refresh and monitor the system
Wider context from the report “(1) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net” should an individual operative not manually refresh and look at the system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to ambulance dispatch and resource-review protocols
Wider context from the report “(1) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net” should an individual operative not manually refresh and look at the system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate or allocate resources when time scales are breached
Wider context from the report “(3) Time scales were breached without further action ie. escalation to Senior Management, Clinicians or allocation of resources.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge, training and understanding of ambulance dispatch and resource-review protocols
Wider context from the report “(2) A lack of knowledge/training/understanding of the protocols that 4 resources were available at different times but none were utilised.
” 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 Reduce the allocation target for amber, soon-to-be-red, calls from two minutes to 30 seconds and disseminate the process through staff training and dispatch guidance.
Verbatim wording from the response “We are also reducing the expected time to allocation for amber details (soon to be Red) from 2 minutes to 30 seconds once coding is confirmed or the detail is available for dispatch from the waiting stack. This change will assist in responding to these patients sooner and reduce any delays at the beginning of the dispatch process. The new process will be discussed, shared and educated on the EOC training away days with all staff and will also be visible on all dispatch bays in the updated Dispatch Quick Reference Guide.” Source location 2017-0133-Response-by-South-Yorkshire-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 Reduce the amber-call resourcing target from 10 minutes to 5 minutes and communicate the revised target to EOC staff.
Verbatim wording from the response “Also the timeframes for resourcing of incidents for amber category calls has been reduced to 5 minutes from the original 10 minutes, this new time target has been communicated to all staff in the EOC. Further awareness on the importance of reviewing available resources will be emphasized to all staff at the EOC training away days throughout June and July 2017.” Source location 2017-0133-Response-by-South-Yorkshire-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 EOC training away days covering role responsibilities, incident review, revision, allocation and timely prioritisation of high-priority calls.
Verbatim wording from the response “The Trust has intense training away days for all EOC staff set up to take place throughout the summer months. Part of these training away days will include reiterating to all EOC staff the core elements of their role, especially around the fundamental aspects of review, revise and allocate with emphasis on not delaying allocation to high priority calls.” Source location 2017-0133-Response-by-South-Yorkshire-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 Introduce a CAD minus-minute indicator showing how long each incident has remained without an allocated resource.
Verbatim wording from the response “We have also further introduced a systems change to assist the EOC management teams with identifying details that have not had a resource allocated within time scales. The system now shows a “minus minute” indicator on the Dispatcher’s, Team Leader’s and Duty Manager’s CAD screen which indicates for each incident how many minutes have passed without a resource being allocated. This enables the Team Leader or Duty Manager the ability to monitor all incidents to ensure they are compliant with timescales.” Source location 2017-0133-Response-by-South-Yorkshire-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 Issue an Operational Alert reiterating the need to allocate the most appropriate available resource without delay.
Verbatim wording from the response “The attached (Appendix 1) Operational Alert was produced on 24 April this year to further reiterate to staff the need to allocate the most appropriate resource available without delay.” Source location 2017-0133-Response-by-South-Yorkshire-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 Use monthly one-to-one performance information to monitor dispatchers’ resourcing performance against targets.
Verbatim wording from the response “EOC staff members have monthly 1:1’s at which the Trust are now able to produce personal performance information, this enables the manager to review whether the dispatcher is meeting appropriate targets, this includes information regarding resourcing of incidents. If it is found there are areas which require improvement the Trust allocates a team champion to sit with the staff member to supervise their work until it is felt that the staff member is performing satisfactorily.” Source location 2017-0133-Response-by-South-Yorkshire-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 Identify the possibility of changing the system to flag incomplete resource checks within the target timeframe.
Verbatim wording from the response “There is now a process in place within Emergency Operations Centre (EOC) whereby a “Call Alert” is highlighted on the Dispatcher’s, Team Leader’s and Duty Manager’s computer automated dispatch (CAD) screen. This highlights when an incident has not been allocated. We are also in the process of identifying the possibility of a system change to identify when a resource check has not been completed within the target timeframe. The introduction of these systems enables the direct managers of the Dispatchers to be made aware of any live incidents that have not been allocated a resource during the incident.” Source location 2017-0133-Response-by-South-Yorkshire-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 Implement a CAD Call Alert process that highlights unallocated incidents to dispatch management.
Verbatim wording from the response “There is now a process in place within Emergency Operations Centre (EOC) whereby a “Call Alert” is highlighted on the Dispatcher’s, Team Leader’s and Duty Manager’s computer automated dispatch (CAD) screen. This highlights when an incident has not been allocated. We are also in the process of identifying the possibility of a system change to identify when a resource check has not been completed within the target timeframe. The introduction of these systems enables the direct managers of the Dispatchers to be made aware of any live incidents that have not been allocated a resource during the incident.” Source location 2017-0133-Response-by-South-Yorkshire-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 Introduce a Dispatcher Standard Operating Procedure supporting consistent standards and live-environment incident auditing.
Verbatim wording from the response “We are also in the process of introducing a Standard Operating Procedure (SOP) to ensure that Emergency Operations Centre Dispatchers are delivering consistently good standards of care to the patients of Yorkshire, this is attached (Appendix 2). This process will facilitate a fair and appropriate audit of incidents in the live environment to ensure that Dispatchers are supported in their role and areas of concern are addressed immediately where possible.” Source location 2017-0133-Response-by-South-Yorkshire-Ambulance-Service
Open published response
Concerns raised 8 Lack of medical review during the initial phase of methadone treatment View source Provision of a 7-day methadone supply to a methadone-naive patient View source Absence of systems to audit the effectiveness and reliability of the pre-alert system View source Failure to conduct a face-to-face consultation before prescribing methadone View source Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing View source Lack of staff knowledge and training for reliable actioning of pre-alert requests View source Absence of assessment of psychological issues before methadone prescribing View source Failure to convey all relevant clinical information View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lyndsey Holt · 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
Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical review during the initial phase of methadone treatment
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of a 7-day methadone supply to a methadone-naive patient
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of systems to audit the effectiveness and reliability of the pre-alert system
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests, the importance of doing and conveyance of all relevant clinical information.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a face-to-face consultation before prescribing methadone
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and training for reliable actioning of pre-alert requests
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests , the importance of doing and conveyance of all relevant clinical information.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of assessment of psychological issues before methadone prescribing
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey all relevant clinical information
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests, the importance of doing and conveyance of all relevant clinical information .
” Open source report
27 Oct 2016 Samuel Thomas Lindor Carroll · Prevention of Future Deaths report North Yorkshire (West)
View report summary
Concerns raised 2 Failure of ambulance services to ask for consent before sharing information about suicidal feelings or hospital attendance View source Failure of police officers to ask for consent before sharing information about suicidal feelings or hospital attendance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Thomas Lindor Carroll · 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
Samuel Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance services to ask for consent before sharing information about suicidal feelings or hospital attendance
Wider context from the report “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital.
2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital.
3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police officers to ask for consent before sharing information about suicidal feelings or hospital attendance
Wider context from the report “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital.
2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital.
3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation.
” Open source report
×
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 evidential basis for concluding that ambulance clinicians failed to ask about contacting family is unclear and was not explored with YAS.
Verbatim wording from the response “Having reviewed the statements and documents from the attending YAS clinicians, Mr Carroll was reporting suicidal ideations, was a consenting adult and was taken to a hospital Emergency Department, as a place of safety. They further report that Mr Carroll was on his mobile phone throughout the journey and they believed that he was in contact with his brother. Given that this is all the information that was available to you from YAS, it is difficult to understand the evidential basis for your concern, and as this was not” Source location 2016-0384-Response-by-Yorkshire-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 welfare-assessment and referral practices, including asking about family contact, are considered sufficient to address the concern.
Verbatim wording from the response “Having discussed this matter with a number of colleagues and managers from both the Clinical and Operations Directorates within the Trust, I can confirm that whilst not formalised in any written process, it is standard practice amongst clinicians as part of any welfare assessment of the patient to ask if there is any family member that can be contacted.” Source location 2016-0384-Response-by-Yorkshire-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 For patients conveyed to hospital, longer-term management and contacting relatives are primarily the receiving hospital's responsibility, not YAS's.
Verbatim wording from the response “If a decision is made to convey a patient such as Mr Carroll to a hospital or other appropriate place of care, there are commonly discussions had with the patient as to whether a family member can be contacted. The next of kin contact details are recorded on the Patient Care Record (PCR) whenever these can be obtained and this is then handed over to the receiving hospital or healthcare organisation on arrival, along with the duty of care to it. It would be expected that a longer term management plan is then put in place by the hospital for the patient prior to discharge which would include making contact with the patient's relatives where appropriate.” Source location 2016-0384-Response-by-Yorkshire-Ambulance-Service
Open published response
13 Sep 2016 Keith William Rushton · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Inadequacy of ambulance response times View source Failure of telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients 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.
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AI-generated summary
Keith William Rushton · 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
Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of ambulance response times
Wider context from the report “• To review and reconsider the adequacy of the existing response times given the two hour delay in responding to Mr Rushton.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients
Wider context from the report “• To review existing protocols governing the allocation of information by telephone operators to incorporate more comprehensive enquiries with respect to long lays, particularly in the case of obese patients , in order to ensure adequate delivery of appropriate ambulance response times.
” Open source report
Concerns raised 3 Inadequate cross-boundary emergency call routing and inter-service dispatch systems View source Failure to record key information during emergency call handling View source Failure of emergency call location systems to accurately locate incidents 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
Grant Thomas Benson and Gordon Nicky Davidson · 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
Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate cross-boundary emergency call routing and inter-service dispatch systems
Wider context from the report “Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record key information during emergency call handling
Wider context from the report “Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency call location systems to accurately locate incidents
Wider context from the report “Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident . Technological information given by GPS gave an inaccurate location for the incident . The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance . Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these.
” Open source report
Concerns raised 4 Unavailability of a double-crewed ambulance during meal break windows View source Lack of manager notification when a crew unilaterally stands off and support is likely to be delayed View source Lack of training for Emergency Medical Dispatch staff to recognise signs of respiratory difficulty View source Failure of the stand-off process to ensure automatic consideration of all alternative support methods View source See 1 more concern
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
Anthony Offord · 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
Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.
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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a double-crewed ambulance during meal break windows
Wider context from the report “(5) With some diffidence, the point should also be raised that apart from the other lone responders who were available, as referred to in ‘Circumstances of the Death’ above, there was another double crewed ambulance nearby which could very likely have reached the scene as early as 2310 -- a point at which Mr Offord might have been saved. Unfortunately at 2302 this vehicle had become 'unavailable out of meal break window' . I recognise that this is a difficult subject, with valid arguments on both sides. I appreciate that it is a national issue, much debated in the past, and I do no more here than record the position as regards that vehicle.
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of manager notification when a crew unilaterally stands off and support is likely to be delayed
Wider context from the report “(2) That where crew make a unilateral decision to stand off there is no requirement for a manager to be informed, even when there is likely to be a delay in the provision of support .
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for Emergency Medical Dispatch staff to recognise signs of respiratory difficulty
Wider context from the report “(1) There is (apparently) no training given to Emergency Medical Dispatch staff as to signs of respiratory difficulty including the well known relevance of snoring in a person who cannot be roused . This may perhaps require an amendment to the breathing diagnostic tool?
” 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 Yorkshire Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the stand-off process to ensure automatic consideration of all alternative support methods
Wider context from the report “(3) That there is no system to ensure that all alternative methods of support are automatically considered when a stand-off occurs , not simply a double crewed ambulance.
” 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 Update the Safety and Security Policy and strengthen frontline training on dynamic risk assessment for lone responding.
Verbatim wording from the response “The Trust has, however, reviewed and updated the Safety and Security Policy, which covers the process relevant to lone responding. Training and education about the dynamic risk assessment process for frontline responders has been strengthened and awareness about the JDM being implemented in EOC is planned prior to its implementation. Using the JDM will ensure a standardised framework is utilised for all stand-off decisions. Where stand off decisions are made they will be based on dynamic assessment relating to that individual incident with appropriate escalation as required.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Emergency Operations Centre staff to consider all available responder and emergency-service support options in stand-off situations.
Verbatim wording from the response “An information bulletin has been provided to all staff within the EOC to remind them to consider all alternative methods of support in a stand-off situation, including all forms of responders, not just double crewed ambulances, and also, where applicable, other emergency services, such as the police.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide EMD staff with structured training and recurrent certification covering recognition of ineffective and agonal breathing.
Verbatim wording from the response “All EMD’s employed by the Trust undergo a robust training programme. This includes the following:” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Joint Decision Model with manager review, phased staff training and awareness sessions for stand-off decisions.
Verbatim wording from the response “The Trust is implementing a change in current practice within the EOC which is based around the Joint Decision Model (JDM). This is the standard decision decision making model used across the police service in the United Kingdom. The model seeks to bring together the available information pertinent to the decision, reconcile objectives and then enable effective decisions to be made.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate delayed Red 1 and Red 2 incidents to Clinical Duty Managers for further clinical assessment.
Verbatim wording from the response “All Red 1 and Red 2 incidents (whether this relates to a stand-off situation or not) where the estimated time of arrival is greater than the response are actively listened to by clinicians within the clinical hub. Where these delays have been identified they are now escalated to a CDM for further clinical assessment.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing the meal-break policy to ensure it supports staff and patient safety and service quality.
Verbatim wording from the response “The Trust is continuing to review the meal break policy to ensure it meets the needs of both staff and patients in order to provide a safe, effective and quality service.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot unilaterally amend the internationally approved breathing diagnostic tool because it lacks the necessary authority.
Verbatim wording from the response “Specific training in relation to breathing difficulties is incorporated in the above programme and this particular element is heavily embedded in the triage tool. The AMPDS provides the call taker with information about ineffective and agonal breathing and how to recognise this. A breathing diagnostic tool is available to aid the EMD in making decisions about patient’s breathing.” Source location 2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations