Arthur William Jepson · Prevention of Future Deaths report

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Issued 16 Sep 2019•South Yorkshire (Western)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
2

Described in responses

Recipients and published responses

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 to conduct a two-hour review for possible re-categorisation

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Yorkshire Ambulance Service NHS Trust

    Put reporting mechanisms in place to monitor completion of revised call-backs and regular contact for excessive incidents, confirming that responses remain appropriate and safe.

  2. Yorkshire Ambulance Service NHS Trust

    Implement the ratified centralised Senior Clinical Advisor procedure for reviewing overdue incidents, making call-backs, and arranging reassessment or re-categorisation where 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

Failure to conduct a two-hour review for possible re-categorisation

Wider context from the report

“During the inquest, evidence showed:- 1. that the pressure on resources was high that day. 2. that a review at the two hour point should have taken place to ascertain if the matter needed re categorisation. 3. Such a review didn’t happen. 4. Whilst the evidence at inquest was that this is unlikely to have changed the outcome in this case, it was a concern to me that it could be in another case. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Put reporting mechanisms in place to monitor completion of revised call-backs and regular contact for excessive incidents, confirming that responses remain appropriate and safe.

Verbatim wording from the response

“In order to gain assurances that the processes are effective, reporting mechanisms shall be put in place to ensure that the revised call-back procedures are being undertaken and ensuring that any excessive incidents receive regular contact to establish whether the Trust’s response is still appropriate and safe.”

Source location

2019-0300-Response-by-Yorkshire-Ambulance-Service
Page 2 · response
Published 1 November 2019

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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

Implement the ratified centralised Senior Clinical Advisor procedure for reviewing overdue incidents, making call-backs, and arranging reassessment or re-categorisation where needed.

Verbatim wording from the response

“Your letter has prompted the Trust to refresh its approach to dealing with such matters and to build upon work already ongoing within the Emergency Operations Centres (“EOCs”) with improving its processes and procedures. As outlined within the letter from the Trust on 4 October 2019, there is work currently ongoing to create a centralised Senior Clinical Advisor standard operating procedure (“SOP”) and the current call-backs and comfort calls SOP has been identified as forming an integral part of this revised central SOP.”

Source location

2019-0300-Response-by-Yorkshire-Ambulance-Service
Page 1 · response
Published 1 November 2019

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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