PFD report

Jack Alfie Charlie HUBBARD · Prevention of Future Deaths report

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Issued 28 Jan 2019•Inner North London

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
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised2

  1. Delays in calling an ambulance pending contact with the duty manager
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Unreliable decisions about when ambulance attendance is requiredPart of recurring concern: Unreliable emergency access to hospital care
  2. Delays in calling an ambulance pending repeat observations regardless of initial results
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Unreliable decisions about when ambulance attendance is requiredPart of recurring concern: Unreliable emergency access to hospital care
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Delays in calling an ambulance pending contact with the duty manager

Wider context from the report

“I heard evidence that the protocol at Egg Nightclub for calling an ambulance is that before this can happen: 1. the duty manager must be called; and 2. a second set of observations must be taken, regardless of the results of the first. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Unreliable decisions about when ambulance attendance is required; Unreliable emergency access to hospital 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

Delays in calling an ambulance pending repeat observations regardless of initial results

Wider context from the report

“I heard evidence that the protocol at Egg Nightclub for calling an ambulance is that before this can happen: 1. the duty manager must be called; and 2. a second set of observations must be taken, regardless of the results of the first. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Unreliable decisions about when ambulance attendance is required; Unreliable emergency access to hospital care.

Open source report
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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