PFD report

Colin James SLUMAN · Prevention of Future Deaths report

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Issued 21 Jun 2017•Exeter and Greater Devon

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

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 raised4

  1. Insufficient availability of Clinical Supervisors to advise call handlers on appropriate responses
    Part of recurring concern: Failure to ensure adequate supervision of emergency call handlersPart of recurring concern: Insufficient medical staffing capacity for timely patient care
  2. Failure of the emergency response protocol to include dizziness and being alone as important triggers for rapid response to catastrophic haemorrhage
  3. Lack of clinical training for call handlers
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.4

  1. Action

    Introduce a cross-hub hunt group enabling EMAs to obtain support from available clinicians.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
  2. Action

    Add major blood loss categories to the Clinical Supervisors’ Escalation Report.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
  3. Action

    Review clinicians’ rota arrangements to align availability with demand by time and day.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    NHS Pathways content and dispositions are overseen by a clinical governance group and continuously reviewed against guidance, evidence and incidents.

    Stated by NHS EnglandExisting 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

Insufficient availability of Clinical Supervisors to advise call handlers on appropriate responses

Wider context from the report

“(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports. ”

Is this part of a recurring concern?

Yes — Failure to ensure adequate supervision of emergency call handlers; Insufficient medical staffing capacity for timely patient 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

Failure of the emergency response protocol to include dizziness and being alone as important triggers for rapid response to catastrophic haemorrhage

Wider context from the report

“(1) The protocol supplied by NHS Pathways to South Western Ambulance Service Trust (SWAST) call handlers does not include reports of “dizziness” and “patient on their own” as important triggers for a rapid response to a report of catastrophic haemorrhage. ”

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 clinical training for call handlers

Wider context from the report

“(2) Call handlers are not clinically trained and are completely reliant on the Protocol for categorising responses (in this case amber was used). ”

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 constant clinical oversight of all emergency reports

Wider context from the report

“(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports. ”

Is this part of a recurring concern?

Yes — Failure to ensure adequate supervision of emergency call handlers.

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

Introduce a cross-hub hunt group enabling EMAs to obtain support from available clinicians.

Verbatim wording from the response

“In response to continual increases in call volume, the Trust has implemented a virtual telephony system to ensure an available call handler, irrespective of location, will take a 999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are able to seek clinical support from available clinicians irrespective of their hub location, thereby maximising the clinical support available to call handling staff.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 6 · response
Published 28 July 2017

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 major blood loss categories to the Clinical Supervisors’ Escalation Report.

Verbatim wording from the response

“A further system utilised by clinicians within the hub is the Escalation Report. This is a tool on the administrative computers on each Clinical Supervisor’s desk and is designed to assist clinicians to identify incidents that have been triaged to an ‘Amber’ disposition but may be in need of a higher level of urgency. It only includes those incidents where an ambulance has yet to be allocated and relates to those categories of call that have the potential to be life-threatening, as in this instance. A Clinical Supervisor can then review the incidents highlighted by this report and decide whether to call the patient for further triage and upgrade the call where required. Before this incident, ‘major blood loss’ (without other symptoms) did not appear as a category identified on the Escalation report.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 6 · response
Published 28 July 2017

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 clinicians’ rota arrangements to align availability with demand by time and day.

Verbatim wording from the response

“One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 5 · response
Published 28 July 2017

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

Put funding in place to recruit ten additional clinicians.

Verbatim wording from the response

“One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 5 · response
Published 28 July 2017

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 content and dispositions are overseen by a clinical governance group and continuously reviewed against guidance, evidence and incidents.

Verbatim wording from the response

“Additionally, in relation to the use of the system by non-clinically trained call handlers, the content and the disposition levels of the NHS Pathways system is overseen by its National Clinical Governance Group (NCGG). This group is chaired by RCGP and members include all clinical colleges (medical/surgery, nursing/midwifery, paramedics), key stakeholders including patients, services (NASMeD and NHS 111) and pharmacists. The pathways themselves are under constant review, and are revised in response to any changes in guidance (e.g. NICE Guidance), published evidence or any incidents related to use of the system.”

Source location

2017-0200-Response-by-NHS-England
Page 2 · response
Published 28 July 2017

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

Call handlers rely on NHS Pathways, whose response to the first concern is considered sufficient to address concerns about non-clinically trained handlers.

Verbatim wording from the response

“Matter of concern 2) In respect of call handlers not being clinically trained, they are reliant on the software provided (in this instance NHS Pathways) and therefore it is felt that the response from NHS Pathways regarding Matter of Concern 1 should address this concern.”

Source location

2017-0200-Response-by-NHS-England
Page 2 · response
Published 28 July 2017

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

Whether a caller being alone warrants a higher response is already assessed operationally case by case by organisations using NHS Pathways.

Verbatim wording from the response

“The question of raising the level of response because the caller is alone is a complex one which is dependent upon a wide range of factors. These considerations have always been assessed operationally on a case-by-case basis by organisations using the NHS Pathways system.”

Source location

2017-0200-Response-by-NHS-England
Page 2 · response
Published 28 July 2017

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 call handlers receive intensive training, competency assessments, supervised practice, audits and ongoing performance management before and during independent practice.

Verbatim wording from the response

“All call handlers using NHS Pathways undergo an intensive training programme that spans 10 weeks. This programme incorporates several formal training modules focusing on NHS Pathways use, distance learning materials, supervised practice, consolidated practice and a ‘common learning programme’. This common learning is a wider training and development programme ensuring all staff are fully prepared and competently skilled for their role delivering care in the NHS. It includes sessions such as customer service skills, managing vulnerable callers and management of calls with a mental health component.”

Source location

2017-0200-Response-by-NHS-England
Page 2 · response
Published 28 July 2017

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

Adding a dizziness question would not have increased the ambulance response disposition because the blood loss already triggered the relevant response level.

Verbatim wording from the response

“In relation to the queries concerning the content of NHS Pathways, a Lead Clinical Author at NHS Pathways stated that the level of blood loss experienced by Mr Sluman was such that it generated a 19 minute ambulance response. This is the same level of response as would have been generated by a patient in probable clinical shock, i.e. cold, clammy and centrally cyanosed. The addition of a question about dizziness would therefore not have raised the disposition level.”

Source location

2017-0200-Response-by-NHS-England
Page 1 · response
Published 28 July 2017

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

EMAs are not completely reliant on NHS Pathways because clinical escalation, local guidance and supervisory review provide additional safeguards.

Verbatim wording from the response

“In terms of whether EMAs are completely reliant on NHS Pathways to reach a disposition, as the Pathways are meticulously devised by a panel of clinical experts, EMAs are for the most part, able to rely on the disposition reached. However, there are occasions where the Trust does not consider a particular disposition (as would be generated by NHS Pathways) for a specific patient presentation to be appropriate despite being clinically safe. On those occasions, the issues are escalated to NHS Pathways for review. Although the Pathways may be revised as a result, if change is not felt to be clinically necessary, it is for the Trust to determine whether local guidance or SOPs should be implemented to govern a particular situation and accordingly any policies would need to be ratified through internal governance procedures.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 4 · response
Published 28 July 2017

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 considered that adding a dizziness question to the bleeding pathway would not have increased the response disposition.

Verbatim wording from the response

“Following the incident, concerns regarding the bleeding Pathway were quickly identified and escalated by the Trust’s Clinical Lead to NHS Pathways for consideration. The concern as to whether a question relating to dizziness should be incorporated within the bleeding Pathway was first raised on 15th July 2016. The Serious Incident investigation report highlighting these concerns was also shared with their organisation in December 2016. It is the Trust’s understanding that NHS Pathways has considered the concerns raised and do not feel that the addition of a question about dizziness would have raised the disposition level.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 28 July 2017

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-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Develop a patient-centred, clinically driven welfare-call process with early clinician review and reassessment.

    Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
  2. 2

    Review the Welfare Call Standard Operating Procedure.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
  3. 3

    Work towards implementing a single triage system across both clinical hubs.

    Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
  4. 4

    Implement a virtual telephony system to route 999 calls to available call handlers across locations.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.

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 a patient-centred, clinically driven welfare-call process with early clinician review and reassessment.

Verbatim wording from the response

“The Trust has carefully reviewed the Welfare Call Standard Operating Procedure (SOP) and is developing a new process tailored to meet the needs of the patients waiting for an ambulance to arrive. The focus of the new process moves away from a standard time based approach to making welfare calls which are patient centred and clinically driven. The new procedure starts with an early review of calls by a registered clinician who will, if indicated by the information gained through the triage, or if demand is likely to cause a delayed response, contact patients to conduct a more thorough clinical review. This will, in turn, inform any decisions to adjust the disposition and the timing of any further welfare calls required.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 3 · response
Published 28 July 2017

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 Welfare Call Standard Operating Procedure.

Verbatim wording from the response

“The Trust has carefully reviewed the Welfare Call Standard Operating Procedure (SOP) and is developing a new process tailored to meet the needs of the patients waiting for an ambulance to arrive. The focus of the new process moves away from a standard time based approach to making welfare calls which are patient centred and clinically driven. The new procedure starts with an early review of calls by a registered clinician who will, if indicated by the information gained through the triage, or if demand is likely to cause a delayed response, contact patients to conduct a more thorough clinical review. This will, in turn, inform any decisions to adjust the disposition and the timing of any further welfare calls required.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 3 · response
Published 28 July 2017

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

Work towards implementing a single triage system across both clinical hubs.

Verbatim wording from the response

“The Clinical Hubs utilise different triage tools (which was a consequence of the acquisition of Great Western Ambulance Service in 2013); the South Hub using NHS Pathways and the Bristol hub using MPDS for call handlers and PSIAM for clinicians. The Trust is, however, currently looking to implement a single triage system to align the working practices of both hubs.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 5 · response
Published 28 July 2017

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

Implement a virtual telephony system to route 999 calls to available call handlers across locations.

Verbatim wording from the response

“In response to continual increases in call volume, the Trust has implemented a virtual telephony system to ensure an available call handler, irrespective of location, will take a 999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are able to seek clinical support from available clinicians irrespective of their hub location, thereby maximising the clinical support available to call handling staff.”

Source location

2017-0200-Response-by-South-Western-Ambulance-Service
Page 6 · response
Published 28 July 2017

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