PFD report

John SCOTT · Prevention of Future Deaths report

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Issued 14 Feb 2019•Brighton and Hove

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.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 raised6

  1. Failure of the callback process to remain safe for lone callers who become unresponsive
    Part of recurring concern: Unsafe management of ambulance calls involving callers who are alone
  2. Failure to manage support arrangements safely for callers who are alone
    Part of recurring concern: Unsafe emergency call handlingPart of recurring concern: Unsafe management of ambulance calls involving callers who are alone
  3. Failure to ask patients with abdominal pain about a pulsating mass
    Part of recurring concern: Inadequate detection and management of abdominal aortic aneurysms
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.6

  1. Action

    Continuously review waiting-stack calls and relevant incidents to identify whether patients can safely travel to hospital independently.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
  2. Action

    Review worsening care advice, including instructions for first-party callers to call 999 if they become unresponsive.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.
  3. Action

    Undertake a detailed review of additional telephone discriminators for abdominal aortic aneurysm, including risk factors, pain characteristics and organ-dysfunction symptoms.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.10

  1. Position

    NHS Pathways is responsible for setting and changing clinical triage questions, including questions addressing abdominal aortic aneurysm risk.

    Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 callback process to remain safe for lone callers who become unresponsive

Wider context from the report

“3. With regard to Pathways I understand that they have their particular questions but how can a person who is alone when they ring the ambulance service phone the ambulance back if they become unresponsive? This is a nonsense and may well confuse the patient who is ringing. ”

Is this part of a recurring concern?

Yes — Unsafe management of ambulance calls involving callers who are alone.

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 manage support arrangements safely for callers who are alone

Wider context from the report

“(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked: 1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them. 2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling; Unsafe management of ambulance calls involving callers who are alone.

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 ask patients with abdominal pain about a pulsating mass

Wider context from the report

“4. Since we were dealing at this Inquest with a case of previously undiagnosed abdominal aortic aneurysm and since this is not an unusual scenario for Pathways or South East Coast Ambulance to come across, is it not possible to ask the patient whether they can feel anything at the site of the pain e.g., a pulsating mass. This if it is felt, could be a clear diagnostic sign. ”

Is this part of a recurring concern?

Yes — Inadequate detection and management of abdominal aortic aneurysms.

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 establish whether an emergency caller is alone and whether another person can be spoken to

Wider context from the report

“(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked: 1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them. 2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling; Unsafe management of ambulance calls involving callers who are alone.

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 address alternative hospital transport when ambulance arrival is expected to take two hours or more

Wider context from the report

“At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival. If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance? ”

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 explain the likely ambulance timing and estimated time of arrival

Wider context from the report

“At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival. If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance? ”

Is this part of a recurring concern?

Yes — Unreliable communication of ambulance dispatch status and expectations.

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

Continuously review waiting-stack calls and relevant incidents to identify whether patients can safely travel to hospital independently.

Verbatim wording from the response

“Clinicians and the Clinical Safety Navigator constantly review calls in the waiting stack and will review incidents that may be deemed appropriate and safe for the patient to make their own way to hospital. The clinician will exclude any high risk symptoms that may put the patient at risk if they made own way, such as the patient feeling faint and can only drive themselves - this would not be appropriate as they could collapse whilst driving and cause greater harm to themselves and other members of the public.”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 June 2019

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 worsening care advice, including instructions for first-party callers to call 999 if they become unresponsive.

Verbatim wording from the response

“For all calls that go through NHS Pathways, care advice and closing instruction are provided at the end of each call by the call handlers. This advice instructs the patient how to look after themselves either while waiting for an ambulance to arrive or another health care professional to contact them or what to do if there is any deterioration. NHS Pathways constantly reviews all clinical content and is currently reviewing all aspects of the care advice given. One part of this review by NHS Pathways will be looking at the worsening advice which is currently given, this will include specifically reviewing the advice to call 999 if deterioration happens, such as for 1st party callers becoming unresponsive, as you suggest.”

Source location

2019-0051-Response-by-NHS-Digital
Page 4 · response
Published 2 June 2019

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

Undertake a detailed review of additional telephone discriminators for abdominal aortic aneurysm, including risk factors, pain characteristics and organ-dysfunction symptoms.

Verbatim wording from the response

“NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

Source location

2019-0051-Response-by-NHS-Digital
Page 5 · response
Published 2 June 2019

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 closing instruction for callers alone, consider adding advice to call someone else, and work with 999 services on its development.

Verbatim wording from the response

“NHS Pathways will review this instruction in line with its review process and consider adding in a statement to “call someone else” and work closely with all 999 services using NHS Pathways in this development. If changes are required these will be incorporated into release 19 (due for deployment May 2020) following NHS Pathways robust processes for authoring, assuring, testing and deployment of clinical content.”

Source location

2019-0051-Response-by-NHS-Digital
Page 3 · response
Published 2 June 2019

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

Deploy a call-handler script advising callers of the ambulance’s estimated arrival timeframe to support informed decisions about waiting or travelling to hospital safely.

Verbatim wording from the response

“Within NHS Pathway release 17 which is being deployed from 5th May 2019 call handlers will be provided with a script to advise callers that an ambulance aims to be with you within x minutes or hours. This was introduced to enable patients to make an informed decision as to whether to wait for that ambulance or, where safe, make their own way to hospital.”

Source location

2019-0051-Response-by-NHS-Digital
Page 3 · response
Published 2 June 2019

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 the resulting abdominal aortic aneurysm triage changes into release 18.

Verbatim wording from the response

“NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

Source location

2019-0051-Response-by-NHS-Digital
Page 5 · response
Published 2 June 2019

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

NHS Pathways is responsible for setting and changing clinical triage questions, including questions addressing abdominal aortic aneurysm risk.

Verbatim wording from the response

“4. All clinical questions that are asked as part of the NHS Pathways triage system are set by the NHS Pathways clinical team and as such, cannot be changed by SECAMb. We understand from ████████ of NHS Pathways that the issue of additional questions to exclude abdominal aortic aneurysm will be part of a review into severe abdominal pain which NHS Pathways already have under way.”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 June 2019

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

NHS Pathways is responsible for amending the script to ask whether patients are alone and provide corresponding instructions.

Verbatim wording from the response

“We therefore defer to NHS Pathways to make any appropriate amendment or addition to the script to enquire as to whether the patient is alone and to amend the instructions to them accordingly. We meet with NHS Pathways on a monthly basis and we have discussed this matter with them. We understand that it is under their consideration (see more in this regard at point 3 below).”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 2 June 2019

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

Advice to call the ambulance service if the patient becomes unresponsive is outside the service’s control because it is prescribed by NHS Pathways.

Verbatim wording from the response

“3. The advice to call back to the ambulance service if the patient becomes unresponsive is part of the NHS Pathways prescribed script and as such is outside of SECAMb’s control. In relation to this issue and those above, NHS Pathways have advised us that care instructions are currently being reviewed for inclusion hopefully into Pathways version 18 which is due for release in the autumn of this year. First party instructions (instruction direct to the patient) will now be part of that review. Given the time constraints they have on releases (including testing and clinician governance prior to release), it is possible that resulting revisions will be included in version 19 rather than version 18.”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 June 2019

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 service cannot provide an ambulance arrival timeframe because multiple factors determine when a particular ambulance resource will arrive.

Verbatim wording from the response

“Paragraph two - We cannot provide a timeframe as there are so many factors involved in determining when an ambulance resource will arrive with any particular patient. We do have a “surge script” which we use when calls could potentially wait longer than the specified timeframe set by the category of call (eg. category 3 – 2 hours). I attach a copy of the script.”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 June 2019

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 service cannot add contradictory instructions to its own script because it must follow NHS Pathways and this could confuse callers.

Verbatim wording from the response

“1. The question of whether a patient is alone would have to form part of the script written by NHS Pathways. The direction “once this phone call is finished, don’t ring anyone else in case we need to call you back” is part of the current Pathways script. Giving the caller the opportunity to ring someone to come to them if they are alone therefore also falls within the NHS Pathways part of the script. It would follow naturally from asking the caller if they are alone. We are obliged to adhere to the Pathways script to maintain our Pathways licence. Whilst we can add our own script after the Pathways script, it would not be sensible and would lead to confusion if we were to contradict instructions we had just given as part of the Pathways script.”

Source location

2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 2 June 2019

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 decision to require call handlers to ask whether another person is present is an operational matter for South East Coast Ambulance Service.

Verbatim wording from the response

“Call handlers using NHS Pathways are always trained to speak directly with the patient when it is a 3rd party call, this ensures that the questions being asked are answered as accurately as possible to ensure both a safe outcome and that questions are not mis-interpreted through a 3rd party. Call handlers are not trained to ask if there is someone else with a 1st party caller, however this is assessed on a case by case basis as there are certain situations where it may not be appropriate to speak with the patient including, but not limited to, children of certain ages, callers with communication difficulties, those with hearing disabilities or so ill they cannot speak. The decision whether to ask all call handlers to ask to speak to someone else if they are with the caller would be an operational decision for South East Coast Ambulance Service as NHS Pathways cannot mandate this.”

Source location

2019-0051-Response-by-NHS-Digital
Page 3 · response
Published 2 June 2019

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 triage identifies hypovolaemia and critical illness for emergency dispatch, so detecting a pulsatile mass would not necessarily change the disposition.

Verbatim wording from the response

“NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

Source location

2019-0051-Response-by-NHS-Digital
Page 5 · response
Published 2 June 2019

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

Telephone palpation by patients or carers is too difficult and could delay ambulance dispatch for a time-critical condition.

Verbatim wording from the response

“Academic studies on abdominal palpation, by trained clinicians, for identifying the presence of AAA have shown not only poor diagnostic accuracy but also wide interobserver variability, affected by the size of both the aneurysm and the patients’ abdomen.”

Source location

2019-0051-Response-by-NHS-Digital
Page 4 · response
Published 2 June 2019

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 instruction not to contact others after ambulance dispatch remains necessary because ambulance services may need to call patients back.

Verbatim wording from the response

“Within NHS Pathways, where there is an ambulance dispatch in both 999 and 111, callers are advised to not to ring anybody else since the ambulance service needs to call the patient back for example to confirm the address or any special requirements like entry information. This is especially important in calls generated from 111 as these are automatically sent through to the ambulance service and the service that has received the case may need to call back.”

Source location

2019-0051-Response-by-NHS-Digital
Page 3 · response
Published 2 June 2019

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

Exact ambulance arrival times can only be provided by South East Coast Ambulance Service using its live operational information.

Verbatim wording from the response

“However, exact times cannot be given by NHS Pathways as this information can only be provided by South East Coast Ambulance Service based on their live operational position and so NHS Pathways cannot comment further on this point.”

Source location

2019-0051-Response-by-NHS-Digital
Page 4 · response
Published 2 June 2019

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