PFD report

Fern-Marie CHOYA · Prevention of Future Deaths report

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Issued 31 Jul 2019•Inner North London

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

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 include pregnancy information in pre-hospital alerts
    Part of recurring concern: Unreliable hospital pre-alert systems
  2. Failure to involve the obstetric team in the assessment and management of pregnant emergencies
    Part of recurring concern: Failure to reliably recognise when obstetric input is needed and obtain it promptlyPart of recurring concern: Unreliable communication and coordination across maternity care providers
  3. Failure to communicate pregnancy information effectively on hospital arrival
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable clinical handover processes
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.12

  1. Action

    Update pre-alert guidance to require the EOC to ask for other specific and critical information during information read-back.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  2. Action

    Update joint maternity training to include EOC staff alongside operational, midwifery and maternity support staff.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  3. Action

    Complete an EOC observation session for the crew to support learning from the incident.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The failure to communicate pregnancy information involved both the crew and emergency operations centre, not the emergency operations centre alone.

    Stated by London 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 include pregnancy information in pre-hospital alerts

Wider context from the report

“1. The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice. However, they failed to include in that alert the information that Ms Choya was pregnant. This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene. ”

Is this part of a recurring concern?

Yes — Unreliable hospital pre-alert systems.

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 involve the obstetric team in the assessment and management of pregnant emergencies

Wider context from the report

“3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise when obstetric input is needed and obtain it promptly; Unreliable communication and coordination across maternity care providers.

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 communicate pregnancy information effectively on hospital arrival

Wider context from the report

“2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable clinical handover processes.

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 recognising pregnancy and calling the obstetric team

Wider context from the report

“2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise when obstetric input is needed and obtain it promptly.

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

Update pre-alert guidance to require the EOC to ask for other specific and critical information during information read-back.

Verbatim wording from the response

“To support crews and the EOC, the LAS has also recently re-issued guidance (on 12 August 2019) to clarify the relevant details expected during pre-alert calls, to ensure that the appropriate clinical team is present on a patient’s arrival. This guidance stipulates the CASMEET mnemonic (please see attached Bulletin). As a result of our learning from Ms Choya’s death, the LAS has extended this guidance to include a request from the EOC for ‘any other specific and critical information’ at the end of the radio transmission when they repeat the information provided back to the crew. Operational staff will be made aware of this change.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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

Update joint maternity training to include EOC staff alongside operational, midwifery and maternity support staff.

Verbatim wording from the response

“We have also already recognised a gap in understanding of maternity calls, between the EOC, frontline operations and maternity units. As such, the LAS has undertaken extensive learning around handovers and this will continue as part of the joint learning with the Whittington Hospital. The LAS uses Managing Maternity Emergencies in Pre-Hospital Setting’ which was established in 2015. The LAS Practice Leads for pre-hospital maternity care updated this joint training in April 2019 to include staff working within the EOC. This was initially in response to identified areas for improvement regarding the communication and management of maternity calls from midwives working in the pre-hospital setting. Every multi-professional maternity training now involves operation road staff, EOC staff and midwives as well as maternity support workers.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 3 · response
Published 18 October 2019

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

Complete an EOC observation session for the crew to support learning from the incident.

Verbatim wording from the response

“Prior to the Inquest, a meeting was held with the crew regarding this incident and feedback provided during this de-brief meeting. In addition, the crew are also to attend an observation session in the EOC for learning purposes (to be completed by 14 October 2019). Furthermore, the relevant Clinical Team Leader will be reviewing, with the crew, what they have learnt from that session and seeking confirmation that they will be following a structured approach every time they share information with the EOC about patients or hand them over to an emergency department in the future.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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

Assess the feasibility of adding a handover audit mechanism to the developing electronic patient care record specification.

Verbatim wording from the response

“As part of this handover procedure, receiving teams are expected to observe a 30 second “hands off eyes on time” period to ensure quiet whilst vital information is conveyed using the ATMIST AMBO (age, time, mechanism/medical complaint, injuries/information related to complaint, signs, treatment – allergies, medication, background/history, other information) mnemonics. The LAS will be rolling out the extension of this handover tool/procedure to all receiving centres, as per the attached handover documents. Work will also be done to ascertain the feasibility of establishing a handover audit mechanism in the specification of the Electronic Patient Care Record (EPCR) that is being developed by the LAS alongside the introduction of its replacement Computer Aided Dispatch (CAD) system.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 3 · response
Published 18 October 2019

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

Roll out the cardiac-arrest handover procedure and ATMIST AMBO tool to all receiving centres.

Verbatim wording from the response

“As part of this handover procedure, receiving teams are expected to observe a 30 second “hands off eyes on time” period to ensure quiet whilst vital information is conveyed using the ATMIST AMBO (age, time, mechanism/medical complaint, injuries/information related to complaint, signs, treatment – allergies, medication, background/history, other information) mnemonics. The LAS will be rolling out the extension of this handover tool/procedure to all receiving centres, as per the attached handover documents. Work will also be done to ascertain the feasibility of establishing a handover audit mechanism in the specification of the Electronic Patient Care Record (EPCR) that is being developed by the LAS alongside the introduction of its replacement Computer Aided Dispatch (CAD) system.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 3 · response
Published 18 October 2019

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

Develop a comprehensive cardiac-arrest handover procedure with tertiary centres to ensure key clinical information reaches receiving teams.

Verbatim wording from the response

“The LAS has liaised with tertiary centres to develop a comprehensive handover procedure in relation to cardiac arrests, ensuring that relevant and key important clinical information is shared with the receiving team.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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

Make operational staff aware of the updated pre-alert guidance.

Verbatim wording from the response

“To support crews and the EOC, the LAS has also recently re-issued guidance (on 12 August 2019) to clarify the relevant details expected during pre-alert calls, to ensure that the appropriate clinical team is present on a patient’s arrival. This guidance stipulates the CASMEET mnemonic (please see attached Bulletin). As a result of our learning from Ms Choya’s death, the LAS has extended this guidance to include a request from the EOC for ‘any other specific and critical information’ at the end of the radio transmission when they repeat the information provided back to the crew. Operational staff will be made aware of this change.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.

Verbatim wording from the response

“Prior to the Inquest, a meeting was held with the crew regarding this incident and feedback provided during this de-brief meeting. In addition, the crew are also to attend an observation session in the EOC for learning purposes (to be completed by 14 October 2019). Furthermore, the relevant Clinical Team Leader will be reviewing, with the crew, what they have learnt from that session and seeking confirmation that they will be following a structured approach every time they share information with the EOC about patients or hand them over to an emergency department in the future.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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

Launch criteria for initiating an obstetric call before a patient's arrival, jointly agreed by obstetric and emergency teams.

Verbatim wording from the response

“2. A set of criteria have been developed to determine if an obstetric call needs to be initiated prior to patient arrival. The Trust already has a process in place for trauma calls, which has now been expanded to cover obstetric callout criteria. In agreeing the criteria, advice was sought from Emergency Department colleagues in other trusts to see if similar systems were already in place and the final criteria were agreed jointly with our obstetrics and emergency teams. The new criteria have now been launched in the Emergency Department. A copy of the criteria is included in Appendix B.”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Design SBAR handover into electronic clinical notes used from patient presentation through discharge.

Verbatim wording from the response

“4. Further work is being undertaken across the Trust in order to standardise handover between clinicians by using the “SBAR” format (Situation, Background, Assessment, Recommendation). This has already been included in the new junior doctor’s induction to the Emergency Department and is being designed into the electronic clinical notes that are used to hand over a patient at any point from presentation to discharge.”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Include SBAR handover training in the Emergency Department junior doctors' induction.

Verbatim wording from the response

“4. Further work is being undertaken across the Trust in order to standardise handover between clinicians by using the “SBAR” format (Situation, Background, Assessment, Recommendation). This has already been included in the new junior doctor’s induction to the Emergency Department and is being designed into the electronic clinical notes that are used to hand over a patient at any point from presentation to discharge.”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Replace the Emergency Department priority-call information sheet with a version prompting staff to ask whether a relevant patient is pregnant.

Verbatim wording from the response

“1. We have modified the Emergency Department ‘Priority call information sheet’ which is used when recording call details received from London Ambulance Service red phone. The sheet now includes a prompt for Whittington Health staff to ask if the patient is pregnant, where relevant. This new sheet replaced the original form in the”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 1 · response
Published 18 October 2019

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 failure to communicate pregnancy information involved both the crew and emergency operations centre, not the emergency operations centre alone.

Verbatim wording from the response

“Notwithstanding the fact that our further review of the transcript has indicated that it was both the crew and the EOC, rather than the EOC alone which failed to pass on the information that Ms Choya was pregnant, LAS acknowledges that, had the correct information been passed, the focus of Ms Choya’s treatment may have been different.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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 existing SBAR handover tool is considered sufficient to help crews convey relevant information to emergency departments, including in stressful circumstances.

Verbatim wording from the response

“The LAS currently utilises the SBAR tool for all patient handovers (Situation, Background, Assessment, and Recommendation). This enables crews to be confident that they have passed relevant information onto emergency departments when handing over patients, even in the most stressful scenarios. However, the importance of relaying the important medical information at handover has been stressed to the crew who provided care to Ms Choya, as a part of the feedback and de-brief meetings referred to above.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 2 · response
Published 18 October 2019

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 department’s treatment decisions are the Whittington Hospital’s responsibility, although LAS measures may support more timely future care.

Verbatim wording from the response

“3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 3 · response
Published 18 October 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Review the clinical opinion provider’s checking of call details to improve report accuracy and consistency.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  2. 2

    Inform HSIB of inaccurate report information and provide details of recurrence-prevention actions.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  3. 3

    Arrange a joint learning and training session with Whittington Hospital to share learning from the case.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  4. 4

    Establish a continuing programme of future simulation drills to support shared learning after the initial exercise.

    Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  5. 5

    Run a simulation exercise with London Ambulance Service to prepare staff for receiving a critically unwell obstetric patient.

    Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.

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 clinical opinion provider’s checking of call details to improve report accuracy and consistency.

Verbatim wording from the response

“The LAS will be informing the HSIB about the inaccurate information that was fed into its report and will be providing the HSIB with details of the actions that the LAS has taken to avoid a recurrence of this. At the same time, an appropriate review of the LAS clinical opinion provider will be undertaken to highlight the importance of checking call details with the EOC, and in order to ensure accuracy and consistency in the Trust’s approach in feeding into other organisations’ reports.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 1 · response
Published 18 October 2019

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

Inform HSIB of inaccurate report information and provide details of recurrence-prevention actions.

Verbatim wording from the response

“The LAS will be informing the HSIB about the inaccurate information that was fed into its report and will be providing the HSIB with details of the actions that the LAS has taken to avoid a recurrence of this. At the same time, an appropriate review of the LAS clinical opinion provider will be undertaken to highlight the importance of checking call details with the EOC, and in order to ensure accuracy and consistency in the Trust’s approach in feeding into other organisations’ reports.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 1 · response
Published 18 October 2019

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

Arrange a joint learning and training session with Whittington Hospital to share learning from the case.

Verbatim wording from the response

“We have discussed Ms Choya’s case with the Whittington Hospital at Clinical Lead, Medical Lead and Director level and are in the process of arranging a session with the Whittington Hospital in light of the learning from Ms Choya’s death.”

Source location

2019-0281-Resposne-by-London-Ambulance-Service
Page 3 · response
Published 18 October 2019

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 continuing programme of future simulation drills to support shared learning after the initial exercise.

Verbatim wording from the response

“3. We are planning a simulation exercise with London Ambulance Service to prepare staff on how to receive a critically unwell obstetric patient. The details of this are being planned but we aim to run the drill in September. This will build on lessons from sessions London Ambulance service has run with other acute Trusts. Following the first simulation, a programme will be established for future drills to ensure continuous ongoing shared learning.”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Run a simulation exercise with London Ambulance Service to prepare staff for receiving a critically unwell obstetric patient.

Verbatim wording from the response

“3. We are planning a simulation exercise with London Ambulance Service to prepare staff on how to receive a critically unwell obstetric patient. The details of this are being planned but we aim to run the drill in September. This will build on lessons from sessions London Ambulance service has run with other acute Trusts. Following the first simulation, a programme will be established for future drills to ensure continuous ongoing shared learning.”

Source location

2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Page 2 · response
Published 18 October 2019

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