PFD report

Rio Andrew · Prevention of Future Deaths report

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Issued 26 Jan 2016•South 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.

View original report
Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

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 raised5

  1. Lack of regulation of individuals calling themselves ambulance technicians
    Part of recurring concern: Failure to protect safety-critical healthcare professional titles
  2. Poor medical knowledge among private medical staff
  3. Failure to ensure the suitability of mentors for trainee medical staff
    Part of recurring concern: Unreliable supervision and competence assurance for trainee medical staff
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

    Consult on whether established year-round event medical providers should be brought within CQC regulation.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 January 2016.
  2. Action

    Work with the College of Paramedics to progress protection and regulation of the Ambulance Technician title.

    Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2016.
  3. Action

    Raise concerns with the Care Quality Commission about regulation of private ambulance providers’ event medical care.

    Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 26 January 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Temporary-event providers remain outside CQC regulation because regulation is ineffective for short events and would impose disproportionate burdens.

    Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Lack of regulation of individuals calling themselves ambulance technicians

Wider context from the report

“(2) This lack of regulation extends to individuals calling themselves ambulance technicians. They are not regulated and the title is not protected. ”

Is this part of a recurring concern?

Yes — Failure to protect safety-critical healthcare professional titles.

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

Poor medical knowledge among private medical staff

Wider context from the report

“(1) The regulation of the private company by the CQC provided false security as to what was in fact being regulated. The only activity that was regulated was transport from the rave in an ambulance on a public road, which activity was not in fact needed because Rio was handed over to the London Ambulance Service outside the venue. The level of medical knowledge displayed by the private medical staff was poor. The exemption for temporary arrangements means that the provision of medical assistance at events is entirely unregulated. This includes not only illegal raves, but legal events such as sporting events, fetes and festivals. ”

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 ensure the suitability of mentors for trainee medical staff

Wider context from the report

“(3) Individuals undergoing training at Lifeskills UK Ltd (and possibly other private training providers) are left to find their own mentor(s) without checks being made by the company as to their suitability or any register or panel from which the choice can be made. ”

Is this part of a recurring concern?

Yes — Unreliable supervision and competence assurance for trainee medical staff.

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 regulation of medical assistance at events

Wider context from the report

“(1) The regulation of the private company by the CQC provided false security as to what was in fact being regulated. The only activity that was regulated was transport from the rave in an ambulance on a public road, which activity was not in fact needed because Rio was handed over to the London Ambulance Service outside the venue. The level of medical knowledge displayed by the private medical staff was poor. The exemption for temporary arrangements means that the provision of medical assistance at events is entirely unregulated. This includes not only illegal raves, but legal events such as sporting events, fetes and festivals. ”

Is this part of a recurring concern?

Yes — Inadequate regulatory oversight of organised public events.

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 protection for the ambulance technician title

Wider context from the report

“(2) This lack of regulation extends to individuals calling themselves ambulance technicians. They are not regulated and the title is not protected. ”

Is this part of a recurring concern?

Yes — Failure to protect safety-critical healthcare professional titles.

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

Consult on whether established year-round event medical providers should be brought within CQC regulation.

Verbatim wording from the response

“The Department has become aware of some permanent established companies that provide cover at temporary events. These providers deliver services on a year round basis, to one off events and other social and cultural events. The range of services provided appears to go some way beyond basic first aid and in some cases involves the delivery of services by a multi-disciplinary team. The Department is intending to consult later this year as to whether providers of this sort should be brought into the scope of regulation by CQC. The Department is proposing that permanent nature of these providers, as opposed to the temporary nature of the events they provide services at, does offer sufficient continuity of service that system regulation by CQC could help mitigate the risks of the public receiving unsafe care at events.”

Source location

Rio-Andrew-2016-Response-by-Department-of-Health
Page 2 · response
Published 26 January 2016

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 with the College of Paramedics to progress protection and regulation of the Ambulance Technician title.

Verbatim wording from the response

“We are also aware of course that the term ‘Ambulance Technician’ is not a protected title and is not regulated. The College of Paramedics has been lobbying for some time to have this title protected and to bring Ambulance Technicians under the same level of regulation as Paramedics. AACE is supportive of this and works closely with the College of Paramedics to attempt to progress this issue.”

Source location

Rio-Andrew-2016-Response-by-Association-of-Ambulance-NHS
Page 1 · response
Published 26 January 2016

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

Raise concerns with the Care Quality Commission about regulation of private ambulance providers’ event medical care.

Verbatim wording from the response

“AACE remains concerned that private ambulance providers who are providing medical cover at events remain unregulated by CQC in terms of the medical care they are delivering within the event footprint. We have raised this previously with CQC and whilst we appreciate the additional workload it would bring them it is clear that times the medical care provided can be tragically inadequate. This also brings an unquantifiable additional burden for the statutory ambulance service who have to intervene and also puts patients at risk.”

Source location

Rio-Andrew-2016-Response-by-Association-of-Ambulance-NHS
Page 1 · response
Published 26 January 2016

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

Temporary-event providers remain outside CQC regulation because regulation is ineffective for short events and would impose disproportionate burdens.

Verbatim wording from the response

“The CQC does not regulate the “treatment of disease, disorder or injury” where it is delivered under temporary arrangements for the purposes of sporting or cultural events. The rationale for this is because the short term nature of such events means system regulation does not offer an effective mitigation of the risks in the care provided over the course of the event. In most cases, the event would be over before the CQC would have chance to inspect it or provided any sort of assurance about the quality and safety of services provided at the event.”

Source location

Rio-Andrew-2016-Response-by-Department-of-Health
Page 2 · response
Published 26 January 2016

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 Care Quality Commission should address regulatory oversight of private ambulance medical care provided at events.

Verbatim wording from the response

“Having considered the issue and discussed with the National Ambulance Medical Directors Group we did feel that we should write to you to make a few salient points and to encourage your engagement with the Care Quality Commission (CQC) to address the regulatory issues.”

Source location

Rio-Andrew-2016-Response-by-Association-of-Ambulance-NHS
Page 1 · response
Published 26 January 2016

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.1

  1. 1

    Review Life Skills Medical UK’s issues and proposals and discuss them with relevant bodies.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 January 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Health and safety enforcement at events is assigned to local authorities or, normally, the Health and Safety Executive.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 Life Skills Medical UK’s issues and proposals and discuss them with relevant bodies.

Verbatim wording from the response

“I note that you have been sent a report from ████████ of Life Skills Medical UK which was, in this case, the Approved Training Centre and Provider of ambulance service qualifications. ████████ made a number of recommendations which he believes would prevent future deaths.”

Source location

Rio-Andrew-2016-Response-by-Department-of-Health
Page 2 · response
Published 26 January 2016

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

Health and safety enforcement at events is assigned to local authorities or, normally, the Health and Safety Executive.

Verbatim wording from the response

“Although Local Authorities are generally responsible for enforcing health and safety legislation at events where an event is actually organised by a local authority, the Health and Safety Executive (HSE) is normally responsible for enforcement. HSE is sponsored by the Department for Work and Pensions.”

Source location

Rio-Andrew-2016-Response-by-Department-of-Health
Page 1 · response
Published 26 January 2016

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