PFD report

William John Puplett · Prevention of Future Deaths report

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Issued 10 Oct 2025•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised1

  1. Failure of emergency dispatch questioning to establish availability of tracheostomy suction equipment and a capable person
    Part of recurring concern: Unreliable Medical Priority Dispatch System emergency assessment and advice pathways
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 of emergency dispatch questioning to establish availability of tracheostomy suction equipment and a capable person

Wider context from the report

“Consideration by the International Academies of Emergency Dispatch to add the following questions when dealing with a patient out of hospital or at home with a tracheostomy tube when there are difficulties with the tracheostomy tube and the patient is experiencing difficulty in breathing. “Have you got suction equipment available and is there someone with the patient who is able to use the suction equipment ? And where the answer is no to either or both the result should be a Category 1 response . ”

Is this part of a recurring concern?

Yes — Unreliable Medical Priority Dispatch System emergency assessment and advice pathways.

Open source report

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.1

  1. 1

    Complete an independent review of the emergency call against IAED performance standards and protocol.

    Stated by International Academies of Emergency DispatchStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The EMD complied with protocol and generated the correct, appropriate dispatch code for the patient’s respiratory distress.

    Stated by International Academies of Emergency DispatchDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Local services, rather than the reviewer, determine actual emergency response assignments.

    Stated by International Academies of Emergency DispatchRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 independent review of the emergency call against IAED performance standards and protocol.

Verbatim wording from the response

“International Academies of Emergency Dispatch Request for Secondary Case Review IAED Independent Case Review”

Source location

Response from International Academies of Emergency Dispatch
Page 1 · response
Published 23 October 2025

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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 EMD complied with protocol and generated the correct, appropriate dispatch code for the patient’s respiratory distress.

Verbatim wording from the response

“Findings: This reviewer found this case to be compliant with the IAED performance standards. The EMD correctly identified the patient as being in obvious respiratory distress. The final MPDS code assignment of 6-D-5 (Breathing Problems/Tracheostomy (obvious distress)) was correct and appropriate.”

Source location

Response from International Academies of Emergency Dispatch
Page 2 · response
Published 23 October 2025

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

Local services, rather than the reviewer, determine actual emergency response assignments.

Verbatim wording from the response

“Remarks: Judging from the audio record, this reviewer has determined the EMD was compliant to protocol. The resulting dispatch code, 6-D-5, was correct and appropriate for this call. The general resource assignment recommendation for this DETA level code is an immediate, ALS-level, Hot (lights and sirens) response. However, actual response assignments are locally determined.”

Source location

Response from International Academies of Emergency Dispatch
Page 2 · response
Published 23 October 2025

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