PFD report

Peter (Peirce) Cotter · Prevention of Future Deaths report

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Issued 20 Sep 2017•Milton Keynes

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
1

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

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Concerns raised1

  1. Failure of clinical decision support software to register head injuries
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Failure to assess and respond promptly to significant signs of injury
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing head-injury questioning and NICE-consistent triage are considered sufficient to identify relevant risks and provide the appropriate emergency response.

    Stated by NHS PathwaysExisting 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

Failure of clinical decision support software to register head injuries

Wider context from the report

“During the course of the evidence it became apparent that Mrs Cotter had telephoned emergency services on 27th January 2017 and reported that her husband had had a fall, hit his head and hurt his hip. My concern is that the clinical decision support software system did not appear to register that Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor head injury could have had catastrophic results if the head injury was not recognised and treated. I believe that there should be a review of the triage system to ensure that all head injuries are recognised and treated as emergencies. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Failure to assess and respond promptly to significant signs of injury.

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing head-injury questioning and NICE-consistent triage are considered sufficient to identify relevant risks and provide the appropriate emergency response.

Verbatim wording from the response

“Having reviewed the case and the Coroner’s concerns, I am in a position to reassure HM Coroner that NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment. In this particular case we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within 1 hour.”

Source location

2017-0388-Response-by-NHS-Digital
Page 2 · response
Published 9 February 2018

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Trust cannot change NHS Pathways because it is designed and managed by NHS Digital.

Verbatim wording from the response

“To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

Source location

2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 9 February 2018

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Responsibility for reviewing and changing NHS Pathways should be directed to NHS Digital.

Verbatim wording from the response

“To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

Source location

2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 9 February 2018

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Notify NHS Digital through its reporting portal of the concerns about head-injury recognition and redirect the PFD report.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 February 2018.

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

Notify NHS Digital through its reporting portal of the concerns about head-injury recognition and redirect the PFD report.

Verbatim wording from the response

“Our EOC Clinical Assurance & Training Manager has notified NHS Digital through their reporting portal of your concerns and that the Trust has advised you to redirect the PFD report to them. Their Clinical Lead is Dr Anil Gill and their contact details are detailed below for you:”

Source location

2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 9 February 2018

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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