Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
× 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 Gap in fitness-to-practise oversight for unregistered technicians
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████ . ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time . I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 assess and manage staff fitness to practise after identified deficiencies
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles . I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Failure of the ambulance service to implement collective learning from identified ECG training gaps
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████ . There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician . Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 correctly interpret 12 lead ECGs
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience .
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 note or act upon auto-diagnostic ECG reports
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report .
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Failure to provide accurate information about observations and ECG findings
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct , and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 qualitative assessment of ECG training
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training . I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time .
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 further ECG training after identified incorrect interpretation
Wider context from the report “Some of the concerns I have identified are directed at multiple organisations and some are specific.
During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████
1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.
2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience.
3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection.
4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg.
5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI.
6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.
7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information.
8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg.
9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time.
10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg . I am concerned this presents a risk to patient safety at this time.
11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest.
12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time.
13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time.
14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS.
” 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 Undertake exploratory work on the patient-safety issues raised about paramedic interpretation of ECGs in the community.
Verbatim wording from the response “On 20 December 2023, our Investigations and Insights team held an Intelligence Review Meeting; at this meeting we review all patient safety concerns and insights received into our organisation and consider them for further exploratory work. I would like to assure you that the Regulation 28 Report sent to us was considered in this meeting, along with other information available to us and I can confirm that further exploratory work is being undertaken in relation to the issues raised in your report.” Source location Response from Health Services Safety Investigations Body
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 exploratory work by the end of January 2024 and consider the scope for an HSSIB investigation.
Verbatim wording from the response “This exploratory work will be further reviewed by the end of January 2024 when we will consider the scope for an HSSIB investigation into issues related to Paramedic interpretation of ECGs in the community.” Source location Response from Health Services Safety Investigations Body
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 Add the individual's name to the HCPC Watchlist.
Verbatim wording from the response “However, I have added her name to our Watchlist. This provides that should she attempt to apply for registration in the future, we will take the concerns you have raised with us into account when considering whether to admit her name to the HCPC Register.” Source location Response from Health and Care Profession Council
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 Trust referral practices to ensure appropriate fitness-to-practise referrals are made.
Verbatim wording from the response “Response
The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.” Source location Response from West Midlands Ambulance Service
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 Deliver an in-person CPD event covering ECG signs and recognition.
Verbatim wording from the response “June 2023” Source location Response from West Midlands Ambulance Service
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 Provide remedial ECG and acute coronary syndrome training to both clinicians through training school.
Verbatim wording from the response “Both the clinicians are booked to attend training school for remedial training on the 1 December 2023. In addition to this ████████ will be meeting with the Trust’s Consultant Paramedic who is the Head of Clinical Care, ████████ to review and reflect on the ECG abnormalities as part of an additional self reflection request.” Source location Response from West Midlands Ambulance Service
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 Publish ACS discharge-on-scene case learning and link staff to ACS educational resources.
Verbatim wording from the response “August 2023” Source location Response from West Midlands Ambulance Service
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 Support a clinician’s attendance on a level-six ECG-in-practice university course.
Verbatim wording from the response “Since the incident ████████ has also requested to attend a level 6 university course to further her knowledge on ECG’s. ████████ has been approved and supported by WMAS to attend a level 6 ECG in practice course, commencing in January 2024.” Source location Response from West Midlands Ambulance Service
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 Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
Verbatim wording from the response “• Evening training session on ECGs and Resus skills delivered” Source location Response from West Midlands Ambulance Service
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 Deliver ECG recognition and advanced life support sessions with Zoll Medical.
Verbatim wording from the response “February 2023” Source location Response from West Midlands Ambulance Service
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 Deliver CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
Verbatim wording from the response “• There was a CPD day at Erdington hub alongside the Research team to provide presentation on STEMI clinical times article on ACS and the new JRCALC update, including the ambulance quality indicators and time from 999 call to inflation of a balloon in a specialist coronary catheter” Source location Response from West Midlands Ambulance Service
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 ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
Verbatim wording from the response “September 2023” Source location Response from West Midlands Ambulance Service
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 Microsoft Teams channel for publishing ECG case studies and facilitating clinical discussion.
Verbatim wording from the response “• Microsoft teams channel set up for regular publication of ECG case studies and to allow for discussion” Source location Response from West Midlands Ambulance Service
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 Issue staff education articles on using ECG monitors’ automatic diagnostic function.
Verbatim wording from the response “As part of the Trusts ongoing education and training for staff we have undertaken a range of initiatives to improve the understanding of ECGs and the auto diagnostic function of ECGs.” Source location Response from West Midlands Ambulance Service
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 Continue monitoring improvements to serious incident management and learning from deaths through ongoing monitoring and engagement.
Verbatim wording from the response “We will continue to monitor WMAS’s progress in making improvements to their serious incident management and learning from deaths through our ongoing monitoring activities and engagement.” Source location Response from Care Quality Commission
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 Organise continuing professional development ECG masterclasses for registered paramedics.
Verbatim wording from the response “▪ The University will organise continuing professional development ECG masterclasses to offer to registered paramedics” Source location Response from University of Wolverhampton
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 Present evidence from the case to students to illustrate harm arising from inadequate ECG understanding and its patient implications.
Verbatim wording from the response “▪ Evidence from the case will be presented to students to exemplify the potential harm from inadequate understanding of the ECG and the implications for the patient – we would welcome a copy of the ECG if this is possible” Source location Response from University of Wolverhampton
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 Incorporate 12-lead ECG interpretation into one or more Objective Structured Clinical Examinations alongside existing practice assessments.
Verbatim wording from the response “▪ Interpretation of 12-lead ECGs will be incorporated into one or more of the Objective Structured Clinical Examinations that students sit throughout their programme. This will supplement rather than replace the current assessments in practice.” Source location Response from University of Wolverhampton
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 Liaise with local coronary care units to obtain anonymised real-patient 12-lead ECG readings for teaching.
Verbatim wording from the response “▪ Members of the paramedic team are liaising with local coronary care units to obtain anonymised 12-lead ECG readings from real patients to further enhance the teaching” Source location Response from University of Wolverhampton
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 Add a 12-lead ECG interpretation workbook to the virtual learning environment and follow up non-completion through personal academic tutors.
Verbatim wording from the response “▪ A 12-lead ECG interpretation workbook will be added to the virtual learning environment for completion by students. Students who do not complete the activity will be followed up by their personal academic tutor” Source location Response from University of Wolverhampton
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 all ECG training and assessment covering ECG abnormalities, pathological implications and appropriate clinical responses.
Verbatim wording from the response “The University understands and accepts without reservation that its training must be effective. We have reviewed all of the ECG training and assessment that takes place on the programme and are confident that our teaching fully covers the abnormalities found in the ECG in this case, the pathological implications of such findings, and the appropriate course of action to be taken.” Source location Response from University of Wolverhampton
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 Concerns about an individual not registered with the HCPC fall outside its remit for further investigation.
Verbatim wording from the response “A review of our Register has revealed that ████████ is not registered with us. As the individual is not registered with us, these concerns do not fall within our remit for further investigation.” Source location Response from Health and Care Profession Council
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 Q-wave changes and AVR deflection are included in training but are not significant features of the high-level ECG competency described.
Verbatim wording from the response “Response
Q wave changes and AVR deflection does feature in our training but is not a significant feature, as this is high level ECG competency. The ECG auto diagnostic did identify an abnormal ECG and this should have been acted upon.” Source location Response from West Midlands Ambulance Service
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 Internal paramedic training includes qualitative ECG assessments, and university course provision is regularly reviewed against Trust and HCPC requirements.
Verbatim wording from the response “Response
In addition to the training evidenced in response to concern 3 & 4, the Trust can confirm that all internally delivered initial paramedic training includes qualitative ECG assessments. ████████ undertook an ECG assessment on 4 August 2020 as part of her Technician training (Appendix 11) which tested her knowledge on ECG interpretation, she passed this assessment with a score of 92.5%. This test covered Q waves and ST elevation.” Source location Response from West Midlands Ambulance Service
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 An employer referral was not considered necessary under HCPC guidance following the serious incident investigation.
Verbatim wording from the response “Response
The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.” Source location Response from West Midlands Ambulance Service
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 There was no evidence of provider-level failure in relation to Miss Lauren Page Smith’s death.
Verbatim wording from the response “Having carefully reviewed the information the trust has provided, we have concluded there is no evidence of provider level failing in relation to Miss Lauren Page Smith’s death. However, we did identify concerns that supported our inspection findings in relation to the serious incident investigation process, and in particular, the timeliness around addressing the training needs of the staff involved with Miss Lauren Page Smith’s care.” Source location Response from Care Quality Commission
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 A fitness-to-practise referral was considered unlikely to meet referral criteria given the employment context, remaining training and registered-paramedic supervision.
Verbatim wording from the response “At the time of the incident, ████████ was working as an employee of WMAS and not in her capacity as a student on placement. As such, WMAS did not notify the University of the incident and we remained unaware of it until two days prior to the receipt of the Regulation 28 report. Had we known earlier, we may have considered whether a referral to an FtP panel was appropriate, but it seems unlikely that the event would have met the criteria for referral. ████████ still had over 15-months of her programme remaining (including the sessions on ECGs), and she was working with a registered paramedic who held overall responsibility and accountability for the decisions made.” Source location Response from University of Wolverhampton
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 Student placement risks are ameliorated because a registered paramedic supervises students and remains responsible and accountable for patient care.
Verbatim wording from the response “████████ commenced her education at the University in June 2022, and is not due to complete her studies until January 2024. It is important to emphasise, that ████████ is not a registered paramedic and will not be eligible to apply for professional registration until such time as she has met all of the outcomes of her current programme of study. As a student, ████████ does not have all of the competencies and skills of a registered paramedic so would be working with a practice educator who is there to support and supervise her as she develops those competencies and skills. It is not expected that she would be making independent decisions on patient care whilst in her role as a student paramedic. The practice educator will always have the ability to override the decision of a student should they deem the proposed course of action to be sub-optimal for the patient.” Source location Response from University of Wolverhampton
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 At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.
Verbatim wording from the response “It should also be noted that on the 6 January 2023, ████████ was working as an employee of WMAS and was not there in her student capacity. ████████ was working within the remit of an associate ambulance practitioner.” Source location Response from University of Wolverhampton
Open published response
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. 7 1 Publish staff communications addressing gender disparity in cardiac care.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 22 November 2023. View source 2 Deliver STEMI care and safety training to clinical team mentors.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 22 November 2023. View source 3 Review non-traumatic chest-pain cases discharged at scene against the clinical risk-assessment tool.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 22 November 2023. View source 4 Develop monitoring of STEMI on-scene times against national ambulance quality indicators and submit it to the national audit group.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 22 November 2023. View source 5 Contact crews involved in STEMI cases where ambulance quality indicators were not met to explore the reasons.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023. View source 6 Share the final inspection report with the coroner after factual accuracy checking.
Stated by Care Quality Commission Stated plannedThe respondent said that this action was planned when they made their response on 22 November 2023. View source 7 Complete core service and well-led inspections of the ambulance trust.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 22 November 2023. View source Recipient positions A position is what a recipient says about a concern when they do not describe a specific action. 2 1 Technicians and student paramedics work with a fully qualified registered paramedic responsible for scene management and clinical decision-making.
Stated by West Midlands Ambulance Service University NHS Foundation Trust Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source 2 The individual had no known affiliation with, and did not undertake paramedic training at, the University of Wolverhampton.
Stated by University of Wolverhampton Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
×
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 Publish staff communications addressing gender disparity in cardiac care.
Verbatim wording from the response “• Article in Weekly Brief on gender disparity in cardiac care” Source location Response from West Midlands Ambulance Service
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 Deliver STEMI care and safety training to clinical team mentors.
Verbatim wording from the response “Prior to the request there were a number of clinical improvements undertaken in relation to cardiac arrest cases, these were;” Source location Response from West Midlands Ambulance Service
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 non-traumatic chest-pain cases discharged at scene against the clinical risk-assessment tool.
Verbatim wording from the response “• Review of cases of all non-traumatic chest pain discharged at scene vs the clinical risk assessment tool” Source location Response from West Midlands Ambulance Service
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 monitoring of STEMI on-scene times against national ambulance quality indicators and submit it to the national audit group.
Verbatim wording from the response “March 2023” Source location Response from West Midlands Ambulance Service
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 Contact crews involved in STEMI cases where ambulance quality indicators were not met to explore the reasons.
Verbatim wording from the response “• The Trust began contacting crew in cases of STEMI where AQI (Ambulance Quality Indicators) was not met to explore reasoning” Source location Response from West Midlands Ambulance Service
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 the final inspection report with the coroner after factual accuracy checking.
Verbatim wording from the response “We carried out core service inspections of WMAS covering urgent and emergency care and the emergency operations centre on 15 to 17 August 2023. An inspection of the well led key question was also carried out between 3 and 5 October 2023. The draft report for these inspections is currently with the provider” Source location Response from Care Quality Commission
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 core service and well-led inspections of the ambulance trust.
Verbatim wording from the response “We carried out core service inspections of WMAS covering urgent and emergency care and the emergency operations centre on 15 to 17 August 2023. An inspection of the well led key question was also carried out between 3 and 5 October 2023. The draft report for these inspections is currently with the provider” Source location Response from Care Quality Commission
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 Technicians and student paramedics work with a fully qualified registered paramedic responsible for scene management and clinical decision-making.
Verbatim wording from the response “Technicians and student paramedics always work with a fully qualified registered paramedic.” Source location Response from West Midlands Ambulance Service
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 individual had no known affiliation with, and did not undertake paramedic training at, the University of Wolverhampton.
Verbatim wording from the response “In respect of Ms Smith, we have reviewed our admissions data and Ms Smith has no known affiliation to the University of Wolverhampton and did not undertake her paramedic training at the University of Wolverhampton.” Source location Response from University of Wolverhampton
Open published response
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