PFD report

David Michael Lee · Prevention of Future Deaths report

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Issued 28 Jun 2017•Manchester North

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised4

  1. Failure to escalate the urgency of requirements for medical assistance
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable escalation by care staff for required medical attention
  2. Lack of training on when to terminate calls with patients
  3. Lack of circulation of call termination guidance to call handling staff
    Part of recurring concern: Unreliable dissemination of safety-critical clinical guidance and learning
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.4

  1. Action

    Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.

    Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2017.
  2. Action

    Revise the call-termination guidance and circulate it to all EOC supervisors.

    Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2017.
  3. Action

    Produce an incident-based case study and use it in scheduled training and workshops for new and existing call takers.

    Stated by North West Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The emergency call was processed correctly and received the correct response code based on the information provided.

    Stated by North West Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 the urgency of requirements for medical assistance

Wider context from the report

“That the call was inappropriately terminated and that this may continue in the future. That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated. Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion. That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Unreliable escalation by care staff for required medical attention.

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

Lack of training on when to terminate calls with patients

Wider context from the report

“That the call was inappropriately terminated and that this may continue in the future. That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated. Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion. That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of circulation of call termination guidance to call handling staff

Wider context from the report

“That the call was inappropriately terminated and that this may continue in the future. That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated. Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion. That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients. ”

Is this part of a recurring concern?

Yes — Unreliable dissemination of safety-critical clinical guidance and learning.

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 appropriately determine when to terminate calls with patients

Wider context from the report

“That the call was inappropriately terminated and that this may continue in the future. That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated. Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion. That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.

Verbatim wording from the response

“EOC Supervisors have subsequently conducted one to one briefings with all call takers in all three EOCs to discuss the guidance and ensure that the practice of terminating calls is fully understood. All call takers are required to provide their signature to confirm that they have read and understood the guidance and its use.”

Source location

2017-0432
Page 2 · response
Published 28 June 2017

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

Revise the call-termination guidance and circulate it to all EOC supervisors.

Verbatim wording from the response

“Following the inquest the Trust have revised the relevant guidance in respect of incidents where call takers should remain on the line and have circulated this to all EOC Supervisors, with the following key points emphasized as direct learning from this case:”

Source location

2017-0432
Page 2 · response
Published 28 June 2017

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce an incident-based case study and use it in scheduled training and workshops for new and existing call takers.

Verbatim wording from the response

“To ensure further Trust wide learning, the Trust’s Legal Department are to produce a case study based on this incident and the appropriate use of call terminations, which will be used in scheduled training sessions/workshops across all EOC’s for new and existing call takers; again to reinforce the practices that should be followed in situations such as this.”

Source location

2017-0432
Page 2 · response
Published 28 June 2017

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

Establish a reminder system to prompt periodic recirculation of call-termination guidance to call takers.

Verbatim wording from the response

“To ensure that the guidance is re-circulated to all call takers at appropriate periodic intervals, the Trust’s Operations Director has also put in place a system whereby he will be periodically reminded to request that the EOC Management team complete the above recirculation process, thus ensuring all call takers are regularly reminded of the practices regarding call termination.”

Source location

2017-0432
Page 2 · response
Published 28 June 2017

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 emergency call was processed correctly and received the correct response code based on the information provided.

Verbatim wording from the response

“I am advised that at the inquest, EOC Deputy Sector Manager Angela Lee gave evidence to the Coroner that the emergency call had been audited and it had been established that it had been processed correctly based on the information given to the call taker and the correct response code was obtained. The call taker stayed on the line with Mr Lee for 30 minutes, however due to Mr Lee telling the call taker that he was starting to feel drowsy, the call taker should have stayed on the line with him until the emergency ambulance arrived. Ms Lee confirmed in evidence that this was an individual error and that the call taker has undertaken a reflective learning exercise in order to identify the error made and reflect on her practice for the future.”

Source location

2017-0432
Page 2 · response
Published 28 June 2017

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