PFD report

Helen BARKER · Prevention of Future Deaths report

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Issued 19 Nov 2019•Lincolnshire

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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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

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Concerns raised2

  1. Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Failure to take timely escalation action when safety thresholds are breachedPart of recurring concern: Unreliable category 3 ambulance assessment and response arrangements
  2. Failure to ensure CAT Team Leader contact with NHS 111 for increasing unassessed category 3 calls passed to the Trust
    Part of recurring concern: Unreliable multi-agency communication procedures
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded

Wider context from the report

“1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:- Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded? ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Failure to take timely escalation action when safety thresholds are breached; Unreliable category 3 ambulance assessment and response arrangements.

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 ensure CAT Team Leader contact with NHS 111 for increasing unassessed category 3 calls passed to the Trust

Wider context from the report

“1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:- Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded? ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

Open source report
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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