PFD report

Mark Bennett · Prevention of Future Deaths report

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Issued 19 Sep 2023•South Yorkshire (Western)

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised2

  1. Lack of guidance or protocols on when to take patients to hospital for thrombolysis
    Part of recurring concern: Unsafe coordination of thrombolysis care
  2. Lack of guidance or protocols on when to stop resuscitation
    Part of recurring concern: Unreliable guidance for decisions to stop or withhold resuscitation
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.5

  1. Action

    Participate in the ongoing national study examining how and where to stop out-of-hospital cardiac-arrest resuscitation attempts.

    Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
  2. Action

    Continue reviewing and updating ambulance clinical guidance regularly and when new evidence becomes available.

    Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
  3. Action

    Update termination-of-resuscitation guidance, extending the recommended termination decision point from 20 to 30 minutes.

    Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing JRCALC guidance provides resuscitation, termination, thrombolysis and conveyance instructions for ambulance clinicians.

    Stated by Association of Ambulance Chief ExecutivesExisting 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 or protocols on when to take patients to hospital for thrombolysis

Wider context from the report

“5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of thrombolysis 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

Lack of guidance or protocols on when to stop resuscitation

Wider context from the report

“5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis. ”

Is this part of a recurring concern?

Yes — Unreliable guidance for decisions to stop or withhold resuscitation.

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

Participate in the ongoing national study examining how and where to stop out-of-hospital cardiac-arrest resuscitation attempts.

Verbatim wording from the response

“We are supportive and engaged with a current and ongoing National Institute for Health Research funded study titled: Exploring and improving resuscitation decisions in out of hospital cardiac arrest. The study aims to determine what is the best approach for deciding when and where to stop resuscitation attempts. Presentation of research findings to a stakeholder group took place on 18th October 23 of which a number of AACE representatives attended. The output from this research will be an evidence informed, ethically grounded, termination of resuscitation guideline, which is acceptable to NHS staff, patients and their relatives. Subject to relevant approval processes, we anticipate that the results of this study may lead to an update to our JRCALC guidance leading to better decisions for patients and their relatives.”

Source location

Response from Association of Ambulance Chief Executives
Page 2 · response
Published 22 November 2023

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 reviewing and updating ambulance clinical guidance regularly and when new evidence becomes available.

Verbatim wording from the response

“The JRCALC guidelines are produced to assist UK Paramedics undertake their role effectively. We appreciate that our clinicians have to make difficult decisions around resuscitation practice, especially in relation to when to commence and when to terminate resuscitation. Many factors need to be taken into account, often rapidly and during stressful situations. We are continually reviewing and updating all our guidance on a regular basis and when new evidence becomes available.”

Source location

Response from Association of Ambulance Chief Executives
Page 2 · response
Published 22 November 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Update termination-of-resuscitation guidance, extending the recommended termination decision point from 20 to 30 minutes.

Verbatim wording from the response

“With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes.”

Source location

Response from Association of Ambulance Chief Executives
Page 1 · response
Published 22 November 2023

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 and update clinical documentation supporting decisions to terminate resuscitation attempts.

Verbatim wording from the response

“Paramedics are also supported to make decisions about the futility of commencing or continuing resuscitation attempts and JRCALC provides clear guidance on the scope in which paramedics may make these difficult decisions. Unfortunately, in this instance, but clearly with the best of intentions, a decision was made which falls outside that scope. On review, YAS documentation could be more supportive in making these decisions. To that end, I have asked that the clinical documentation is reviewed and updated, and decisions relating to the termination of resuscitation attempts are covered as a component of annual clinical refresher training.”

Source location

Response from Yorkshire Ambulance Service
Page 2 · response
Published 22 November 2023

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

Cover decisions to terminate resuscitation attempts in annual clinical refresher training.

Verbatim wording from the response

“Paramedics are also supported to make decisions about the futility of commencing or continuing resuscitation attempts and JRCALC provides clear guidance on the scope in which paramedics may make these difficult decisions. Unfortunately, in this instance, but clearly with the best of intentions, a decision was made which falls outside that scope. On review, YAS documentation could be more supportive in making these decisions. To that end, I have asked that the clinical documentation is reviewed and updated, and decisions relating to the termination of resuscitation attempts are covered as a component of annual clinical refresher training.”

Source location

Response from Yorkshire Ambulance Service
Page 2 · response
Published 22 November 2023

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 JRCALC guidance provides resuscitation, termination, thrombolysis and conveyance instructions for ambulance clinicians.

Verbatim wording from the response

“With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes.”

Source location

Response from Association of Ambulance Chief Executives
Page 1 · response
Published 22 November 2023

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 JRCALC and Resuscitation Council guidelines clearly address resuscitation and potentially reversible causes, including suspected pulmonary embolism.

Verbatim wording from the response

“Nationally, ambulance clinicians follow standard clinical practice guidelines developed and managed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) on behalf of the Association of Ambulance Chief Executives (AACE). These are universally referred to as the JRCALC Guidelines. Guidelines relating to the management of cardiac arrest follow the Resuscitation Council (UK) guidelines. The guidelines are clear on the delivery of Advanced Life Support (ALS) and when to consider that to commence or continue resuscitation attempts would be futile. YAS clinicians have the ability at all times to access these guidelines via an app on a personal issue YAS mobile phone.”

Source location

Response from Yorkshire Ambulance Service
Page 1 · response
Published 22 November 2023

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

  1. 1

    Training and education of ambulance staff are outside AACE’s responsibility.

    Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
  2. 2

    Ambulance trusts are responsible for ensuring cardiac-arrest staff are adequately trained and training is regularly updated.

    Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Training and education of ambulance staff are outside AACE’s responsibility.

Verbatim wording from the response

“AACE are not responsible for the training or education of ambulance staff, however we are aware that ambulance trusts have a responsibility to ensure that staff that attend cardiac arrests are adequately trained and that this training is regularly updated.”

Source location

Response from Association of Ambulance Chief Executives
Page 2 · response
Published 22 November 2023

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

Ambulance trusts are responsible for ensuring cardiac-arrest staff are adequately trained and training is regularly updated.

Verbatim wording from the response

“AACE are not responsible for the training or education of ambulance staff, however we are aware that ambulance trusts have a responsibility to ensure that staff that attend cardiac arrests are adequately trained and that this training is regularly updated.”

Source location

Response from Association of Ambulance Chief Executives
Page 2 · response
Published 22 November 2023

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