PFD report

Prabhabi Cangi · Prevention of Future Deaths report

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Issued 5 Jun 2026•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
10

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. Lack of guidance for clear and readable photographs of ECGs uploaded to attendance records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Lack of a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital
    Part of recurring concern: Unreliable ECG use and interpretation for clinical decisions
  3. Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital
    Part of recurring concern: Failure to provide timely emergency hospital conveyancePart of recurring concern: Unreliable emergency access to hospital care
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.7

  1. Action

    Commence a trial transmitting ECGs to Heart Attack Centre clinicians for early interpretation and specialist referral.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
  2. Action

    Review ECG transmission pilot results and use the findings to inform future pan-London ECG transmission approaches.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
  3. Action

    Commence procurement of ECG monitoring equipment requiring direct ECG data upload into electronic patient care records.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Existing clinical guidance, support lines and planned ECG transmission provide sufficient mechanisms for paramedic escalation and specialist review.

    Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 guidance for clear and readable photographs of ECGs uploaded to attendance records

Wider context from the report

“That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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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 a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital

Wider context from the report

“That there is no clear pathway for interpretation of ECG traces to a specialist doctor, when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital. ”

Is this part of a recurring concern?

Yes — Unreliable ECG use and interpretation for clinical decisions.

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 convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital

Wider context from the report

“That Intermittent symptoms of:- - Chest Pain - Breathlessness - Abnormal ECG with some ST elevation (using one or more leads) did not result in the patient being taken to the nearest emergency hospital. ”

Is this part of a recurring concern?

Yes — Failure to provide timely emergency hospital conveyance; 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

Failure to advise patients with abnormal ECGs to show the ECG copy to their GP

Wider context from the report

“That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital). ”

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

Commence a trial transmitting ECGs to Heart Attack Centre clinicians for early interpretation and specialist referral.

Verbatim wording from the response

“In addition, clinicians have access to real-time clinical support. This includes the LAS Clinical Hub, which is staffed by experienced Clinical Support Managers, and an on-call clinical advice line involving senior paramedics and doctors where escalation is required. In the latter part of this year, the LAS is due to commence a trial of ECG transmission to HAC clinicians for assistance with interpretation. This will facilitate early cardiology review and admission to specialist units as required.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 August 2026

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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

Review ECG transmission pilot results and use the findings to inform future pan-London ECG transmission approaches.

Verbatim wording from the response

“Notwithstanding this, LAS will reinforce guidance relating to intermittent symptoms and potential ACS scenarios; re-emphasise best practice regarding provision of ECG copies and patient advice; and strengthen messaging regarding the clarity and quality of ECG image capture pending implementation of enhanced digital solutions. Furthermore, an interim review of results from ECG transmission to cardiologists is planned once the pilot phase of this programme of work is complete. This will be used to guide and inform future approaches to ECG transmission pan London.”

Source location

Response from London Ambulance Service
Page 4 · response
Published 14 August 2026

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

Commence procurement of ECG monitoring equipment requiring direct ECG data upload into electronic patient care records.

Verbatim wording from the response

“The Trust is also due to commence a procurement process for new ECG monitoring equipment during the 2026–2027 financial year. A key requirement of this procurement is the capability for ECG data to be uploaded directly from monitoring equipment into the ePCR, thereby removing the need for photographic capture and improving accuracy and quality of records.”

Source location

Response from London Ambulance Service
Page 4 · response
Published 14 August 2026

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

Re-emphasise best practice for providing ECG copies and advising patients to share them with subsequent healthcare professionals.

Verbatim wording from the response

“Where a patient is not conveyed to hospital it is standard practice to provide the patient with a paper copy of the ECG; and the patient is advised to retain the ECG and present it to any healthcare professional with whom they subsequently have contact, such as their General Practitioner. In addition to this, following clinical interaction with patients, completed clinical”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 August 2026

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

Reinforce guidance and training on intermittent symptoms and presentations suggestive of acute coronary syndrome.

Verbatim wording from the response

“Conversely, where ECG abnormalities are new, unexplained, or accompanied by symptoms suggestive of acute coronary syndrome, conveyance or onward referral is clearly indicated. LAS clinicians are therefore required to apply clinical judgement in interpreting ECG findings within the wider clinical context, rather than relying solely on automated ECG interpretation or isolated abnormalities.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 August 2026

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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

Deliver further ECG-focused training and updated myocardial infarction guidance through the 2026–2027 Core Skills Refresher cycle.

Verbatim wording from the response

“LAS provides ongoing training and reinforcement of ECG interpretation through:”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 August 2026

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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

Strengthen staff messaging on capturing clear, readable ECG images pending enhanced digital recording solutions.

Verbatim wording from the response

“LAS policy requires that all clinical images, including ECG photographs, are relevant, clear, and clinically usable. The Trust recognises the importance of ensuring that ECG images recorded within the ePCR are consistently clear and readable and will reinforce this requirement with staff.”

Source location

Response from London Ambulance Service
Page 4 · response
Published 14 August 2026

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

Existing clinical guidance, support lines and planned ECG transmission provide sufficient mechanisms for paramedic escalation and specialist review.

Verbatim wording from the response

“This guidance is available to all LAS clinicians and is accessible in real time via Trust-issued electronic devices.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 August 2026

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

Existing paramedic training, national guidance and holistic clinical assessment are considered sufficient for recognising and managing suspected acute coronary syndrome.

Verbatim wording from the response

“Paramedics are required to complete an approved Bachelor of Science degree prior to registration with the Health and Care Professions Council (HCPC). Training in ECG acquisition and interpretation is a core component of paramedic education and includes recognition of features consistent with myocardial ischaemia and infarction, including STEMI.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 August 2026

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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

Existing practice provides patients with ECG copies and advice to share them with subsequent healthcare professionals, including general practitioners.

Verbatim wording from the response

“Where a patient is conveyed to hospital a photograph or digital copy of the ECG is uploaded to the electronic Patient Care Record (ePCR); and a paper copy of the ECG is routinely provided to the receiving clinician during handover.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 August 2026

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

Existing policy requires ECG images to be clear, relevant and clinically usable, providing an established control for record quality.

Verbatim wording from the response

“Quality and Clarity of ECG Records”

Source location

Response from London Ambulance Service
Page 4 · response
Published 14 August 2026

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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

Local ambulance services are responsible for the operational concerns and are best placed to respond to them.

Verbatim wording from the response

“Having reviewed these concerns, and shared them with the ambulance team for comment, we consider that they relate to specific operational matters, which are the responsibility of the local ambulance service. We note that your report has also been addressed to London Ambulance Service, and so we have agreed that they are best placed to respond to your concerns.”

Source location

Response from London Ambulance Service
Page 1 · response
Published 14 August 2026

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.3

  1. 1

    Deliver an ECG interpretation event in conjunction with the Royal College of Paramedics.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
  2. 2

    Share key learnings and insights from Reports to Prevent Future Deaths across national and regional NHS levels.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
  3. 3

    Discuss all received Reports to Prevent Future Deaths through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.

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

Deliver an ECG interpretation event in conjunction with the Royal College of Paramedics.

Verbatim wording from the response

“• An ECG interpretation event delivered in April 2025 in conjunction with the Royal College of Paramedics; and”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 August 2026

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

Share key learnings and insights from Reports to Prevent Future Deaths across national and regional NHS levels.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mrs Cangi, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 August 2026

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

Discuss all received Reports to Prevent Future Deaths through the Regulation 28 Working Group.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mrs Cangi, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 August 2026

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