PFD report

Aidan David Ridley · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 9 Apr 2019•Wiltshire and Swindon

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
8

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised8

  1. Inadequate supervision of Police call handlers
    Part of recurring concern: Failure to ensure adequate supervision of emergency call handlersPart of recurring concern: Unsafe emergency call handling
  2. Limited use of three-way calls between the public, Police call handlers and the ambulance service
    Part of recurring concern: Unsafe emergency call handling
  3. Failure to provide safe advice about turning a person over
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.3

  1. Action

    Implement protocols, staff communication and training requiring police call handlers to avoid first-aid advice and refer medical emergencies to ambulance call handlers.

    Stated by Wiltshire PoliceStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
  2. Action

    Train new call handlers, issue staff briefings and reminders, and regularly test the three-way police-ambulance conferencing process.

    Stated by Wiltshire PoliceStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
  3. Action

    Revise the force procedure for managing calls to reinforce the policy on police call handlers’ medical-advice responsibilities.

    Stated by Wiltshire PoliceStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Police call handlers should not provide first-aid advice; ambulance call-centre staff are responsible for providing that advice.

    Stated by Wiltshire PoliceRedirects 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

Inadequate supervision of Police call handlers

Wider context from the report

“(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively. ”

Is this part of a recurring concern?

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

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

Limited use of three-way calls between the public, Police call handlers and the ambulance service

Wider context from the report

“(5) The system that has been introduced since Aidan's death, of allowing 3 way calls between the member of the public, the police call handler and the ambulance service appears on the evidence heard at the Inquest, to have had little if any use. To what extent does the induction training and the ongoing training of Control room call operators refer to it or demonstrate it in action? ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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 safe advice about turning a person over

Wider context from the report

“(1) The advice by the Police call handler not to turn Aidan over. ”

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 direct members of the public to ambulance-service advice or medically trained people at the scene

Wider context from the report

“(2) The Police call handler did not advise members of the public at the scene to seek advice from the ambulance service or to defer to members of the public present with medical training. ”

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

Inadequate induction and ongoing training on three-way calls

Wider context from the report

“(5) The system that has been introduced since Aidan's death, of allowing 3 way calls between the member of the public, the police call handler and the ambulance service appears on the evidence heard at the Inquest, to have had little if any use. To what extent does the induction training and the ongoing training of Control room call operators refer to it or demonstrate it in action? ”

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 intervene in or correct unsafe call-handler advice

Wider context from the report

“(4) There was a failure to intervene in or correct the advice given by the call handler not to turn Aidan over. ”

Is this part of a recurring concern?

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

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

Inadequate training of Police call handlers

Wider context from the report

“(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively. ”

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

Inadequate guidance for Police call handlers

Wider context from the report

“(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement protocols, staff communication and training requiring police call handlers to avoid first-aid advice and refer medical emergencies to ambulance call handlers.

Verbatim wording from the response

“As events unfolded and it became clearer there was a casualty the call remained with the police as the BT operator had ended their call, there was no facility to transfer the call to ambulance on a priority line. Police call handlers are not trained in first aid and do not receive any training to provide first aid advice. Following this incident clarity on the point of Police call handlers providing first aid was sought from ████████. The National Police Chiefs Council (NPCC) lead for First Aid. The reply from ████████ was they should not provide first aid. This has been communicated to all staff within the Crime & Communication Centre where the call handlers work, and updated protocols now exist between the police and ambulance call centers and are now established which I will detail in a separate report.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 1 · response
Published 2 August 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

Train new call handlers, issue staff briefings and reminders, and regularly test the three-way police-ambulance conferencing process.

Verbatim wording from the response

“The functionality of this system is a standard telephony conferencing. This is trained to all of our new starters as is all other Cortex / Telephony processes. It is fair to say that the set of circumstances relating to the road traffic collision report involving Aidan remain unusual.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 3 · response
Published 2 August 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

Revise the force procedure for managing calls to reinforce the policy on police call handlers’ medical-advice responsibilities.

Verbatim wording from the response

“A variety of training materials (including e-mail reminders about the police sent to staff) were provided by Wiltshire Police as part of the inquest; please let me know if you require further copies of these. Furthermore, as indicated during the inquest, further revisions of the relevant Force procedure on managing calls have now taken place in order to underline the policy to staff.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 3 · response
Published 2 August 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

Police call handlers should not provide first-aid advice; ambulance call-centre staff are responsible for providing that advice.

Verbatim wording from the response

“The fact that medical advice was provided by the call handler in this incident has been the subject of clarification as we sought national guidance from ████████. The advice we received back was that the police call handlers should not provide first aid advice or guidance as they received no formal training for this. This advice has been communicated to all the staff working in the Crime & Communication Centre that handles all the calls and crime reports they will not provide first aid advice or guidance during a call and that they will utilise established protocols to refer the calls on to the ambulance call center who have the training, databases and established protocols to provide first aid advice to the people reporting medical emergencies.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 2 · response
Published 2 August 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

Routine monitoring of every call is not achievable because supervisors have other responsibilities and the control room manages numerous live incidents.

Verbatim wording from the response

“As mentioned, incoming calls are not all routinely monitored by supervisors. The layout of the call center means the Force Incident Manager (Inspector) has responsibility for up to seventeen members of staff who are either taking calls or dispatching units. The inspector may hear one half of the conversation as the operator is speaking. The inspector and supervisors have the ability to dip sample calls of call handlers but also have other roles and responsibilities which include assessing the current active logs across the county. A supervisor could review or monitor the call requested by the call handler. It is routine within the Crime & Communication Centre to have up to 30 live incidents across the county over five different radio channels which places demands on all the staff.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 2 · response
Published 2 August 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

A minor road-traffic-collision report, as initially understood, would not require supervisor oversight under existing procedures.

Verbatim wording from the response

“This call was initially reporting a road traffic collision and this quickly developed into a medical emergency call that was not identified as such at the point the call came to the police. The training given to call handlers enables them to take control of the call and extract relevant information from the caller and remaining calm and reassuring. As information developed a call was made to ambulance by a colleague to ensure an ambulance was attending the scene which was within procedure.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 2 · response
Published 2 August 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 call-handler training and procedures mean there is no longer a substantial risk of incorrect medical advice.

Verbatim wording from the response

“The routine one to one monitoring of individual calls is not achievable between a call handler and supervisor. Structures exist within the teams for a supervisor to provide assistance and the assessment of calls forms part of the ongoing training for quality and standards assurance. As call handlers’ training now clearly excludes the provision of medical advice and instead sets out a simple method for involving the ambulance service, there is no longer any substantial risk of call handlers giving incorrect medical advice. The instructions/training mentioned above are in place both for existing and new call handlers.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 2 · response
Published 2 August 2019

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.2

  1. 1

    Communicate the policy changes to the NPCC and College of Policing.

    Stated by Wiltshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 2 August 2019.
  2. 2

    Provide the response to the NPCC and College of Policing.

    Stated by Wiltshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 2 August 2019.

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

Communicate the policy changes to the NPCC and College of Policing.

Verbatim wording from the response

“We are grateful for the opportunity to reflect on and set out the organisational learning arising from this inquest. As indicated at the inquest, we have also been in communication with the NPCC / College of Policing in respect of the policy changes and will provide them a copy of this response.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 3 · response
Published 2 August 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

Provide the response to the NPCC and College of Policing.

Verbatim wording from the response

“We are grateful for the opportunity to reflect on and set out the organisational learning arising from this inquest. As indicated at the inquest, we have also been in communication with the NPCC / College of Policing in respect of the policy changes and will provide them a copy of this response.”

Source location

2019-0173-Response-by-Wiltshire-Police
Page 3 · response
Published 2 August 2019

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
1/1

Data last updated 7 September 2026