PFD report

Reginald George KEY · Prevention of Future Deaths report

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Issued 24 Jan 2018•Stoke-on-Trent and North Staffordshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of an option for paramedics to return deteriorating patients to hospital
    Part of recurring concern: Unreliable emergency access to hospital care
  2. Delays in patient transport home
    Part of recurring concern: Failure to provide timely non-emergency patient transfers
  3. Failure to identify deterioration during patient transport
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Review the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.

    Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 March 2018.
  2. Action

    Instruct the provider to produce an action plan addressing the identified patient transport safety measures.

    Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 March 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Hospital transfers requiring escalation are handled by the 999 ambulance service, not patient transport staff.

    Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an option for paramedics to return deteriorating patients to hospital

Wider context from the report

“• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home. • Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access to hospital care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in patient transport home

Wider context from the report

“• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home. • Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016. ”

Is this part of a recurring concern?

Yes — Failure to provide timely non-emergency patient transfers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify deterioration during patient transport

Wider context from the report

“• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home. • Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration.

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

Review the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.

Verbatim wording from the response

“We have instructed the provider to produce an action plan to address these matters. This plan will be reviewed in detail at the next provider contract and quality meeting in April 2018 by my commissioning and quality teams and will be monitored at this meeting until all actions are concluded and agreed between the provider organisation and the CCGs.”

Source location

2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
Page 3 · response
Published 20 March 2018

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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

Instruct the provider to produce an action plan addressing the identified patient transport safety measures.

Verbatim wording from the response

“Assurances Undertaken to Prevent Future Deaths To address the Coroner’s concerns we have instructed the provider to act upon the findings and include in their action plan the following:”

Source location

2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
Page 2 · response
Published 20 March 2018

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

Hospital transfers requiring escalation are handled by the 999 ambulance service, not patient transport staff.

Verbatim wording from the response

“We have discussed the level of skill and escalation procedure with the PTS provider. They have reported all staff are aware of the deteriorating patient policy and they expect staff to enact this when they have any patient concerns. Staff are instructed at times of a medical emergency and/or concerns around the patients’ health, that they are to stop the vehicle and inform the ambulance service of the nature of the emergency and await the service to respond. It is important to highlight that they are not allowed to transport a patient to hospital and are required to seek professional help via the 999 service.”

Source location

2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
Page 2 · response
Published 20 March 2018

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

Transport records contradict the reported four-hour journey and record no observed deterioration or route deviation.

Verbatim wording from the response

“17:16 and show that he had been collected by the crew at 17:50. The PTS crew had left the hospital at 18:09 and Mr Key arrived back to his home address in Hednesford at 19:15. We have confirmed that the crew consisted of two patient transport assistants and that these were not paramedics. The PTS service have no record of any concerns being raised by their crew under their deteriorating patient policy and no indication that the crew deviated from the plan as indicated by their transport monitoring system.”

Source location

2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
Page 2 · response
Published 20 March 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026