PFD report

Thomas Alexander Ferdinand MAYHEW (known as Ned) · Prevention of Future Deaths report

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Issued 23 Apr 2026•East Sussex

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 raised1

  1. Delays in routing emergency calls concerning apparently deceased persons to ambulance services
    Part of recurring concern: Unsafe emergency call handling
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.5

  1. Action

    Continue working with operational partners to reflect any agreed improvements appropriately in the PECS Code of Practice.

    Stated by Department for Science, Innovation and TechnologyStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2026.
  2. Action

    Engage operational partners to consider the proposed change and decide whether to adopt it as standard practice.

    Stated by Department for Science, Innovation and TechnologyStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2026.
  3. Action

    Engage ambulance services and the 999 Liaison Committee to consider default ambulance routing for uncertain reports of apparently deceased people.

    Stated by UK policingStated plannedThe respondent said that this action was planned when they made their response on 21 May 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Operational delivery of emergency services, including police and ambulance response and control-room decisions, is outside the department’s responsibility.

    Stated by Department for Science, Innovation and TechnologyOutside remitThe respondent said that this matter was outside its role or authority.

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 routing emergency calls concerning apparently deceased persons to ambulance services

Wider context from the report

“I heard expert evidence from a Consultant Intensive Care Physician, who explained that there is a limited window of time (approximately ten minutes) during which emergency life-saving treatment can be provided to a person who has applied a ligature, such that cerebral hypoxia may be prevented. Cerebral hypoxia, if not reversed, may ultimately lead to cardiac arrest and death. The expert confirmed that if medical intervention is delivered within this critical period, death may be prevented. The expert further confirmed that a person who has applied a ligature may appear deceased to an observer, for example, displaying no movement and being unconscious, while nevertheless remaining within that ten-minute window during which the outcome may still be altered. I also heard evidence regarding the Public Emergency Call Service Code of Practice (“PECS”). I was told that where a member of the public contacts emergency services to report the discovery of an apparently deceased person, the call would likely be directed to the police in line with the PECS. In addition, I heard that where a caller is unsure which emergency service they require, the operator must connect the caller to the police, in accordance with a request made by the National Police Chiefs’ Council. Having considered the expert evidence, I am of the view that in these critical circumstances every second is of importance. The process of routing a caller to the police, who may then refer the matter to the ambulance service and/or instruct an ambulance to attend, carries a risk that valuable minutes may be lost. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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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

Continue working with operational partners to reflect any agreed improvements appropriately in the PECS Code of Practice.

Verbatim wording from the response

“Thank you again for bringing this matter to our attention. We hope this response provides assurance that the issues you have identified are being considered with the seriousness they deserve, and that DSIT will continue to work with operational partners to ensure any agreed improvements are reflected appropriately in the PECS Code of Practice.”

Source location

Response from Department for Science, Innovation and Technology
Page 2 · response
Published 21 May 2026

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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

Engage operational partners to consider the proposed change and decide whether to adopt it as standard practice.

Verbatim wording from the response

“We coordinate closely with emergency service organisations and BT, as the 999 call handling agent, to ensure that the Code of Practice reflects agreed operational practice and supports the prioritisation of life-saving interventions. Following receipt of your report, we have engaged with the relevant operational partners who can advise on the proposal (BT, ambulance services, and policing, including through the 999 Liaison Committee and consultation with the National Police Chiefs' Council (NPCC)) to consider the issues raised and decide whether the proposed change”

Source location

Response from Department for Science, Innovation and Technology
Page 1 · response
Published 21 May 2026

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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

Engage ambulance services and the 999 Liaison Committee to consider default ambulance routing for uncertain reports of apparently deceased people.

Verbatim wording from the response

“Policing has asked BT to engage formally with ambulance services and the 999 Liaison Committee to consider whether, in cases where a caller describes the discovery of a body or an apparently deceased person and is unsure which service is required, calls should default to routing to the ambulance service, which ambulance colleagues have agreed to and the appropriate PECS governance process and training will be updated. This proposal reflects the principle that clinical need should take primacy where there is any possibility that life remains.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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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

Reinforce expectations that police control rooms immediately notify ambulance services when life extinction is uncertain, using guidance and assurance activity.

Verbatim wording from the response

“In addition, UK policing will reinforce national expectations that, where there is any uncertainty as to whether life is extinct, police control rooms must immediately notify ambulance services and not await on-scene confirmation. While this expectation already exists in operational practice, it will be re-emphasised through guidance and assurance activity in light of the issues highlighted by this case.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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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

Support development of rapid call-transfer functionality between police and ambulance services to address identified mis-routing without caller re-dialling.

Verbatim wording from the response

“Policing also supports the continued development of technical solutions, such as onward call connect or rapid call transfer functionality, which would enable emergency calls to be transferred swiftly between police and ambulance services when initial mis-routing is identified, without requiring the caller to re-dial. Although responsibility for such functionality does not sit with policing, we are actively supporting its development and adoption where available.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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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

Operational delivery of emergency services, including police and ambulance response and control-room decisions, is outside the department’s responsibility.

Verbatim wording from the response

“We were very saddened to hear of the case involving Ned, and we wanted to thank you for raising this important matter so that it can be considered by the relevant authorities accordingly. We recognise the seriousness of the issues raised and welcome the opportunity to respond. While we are not responsible for the operational delivery of emergency services, including police and ambulance response or control room decision-making, we maintain the Public Emergency Call Service (PECS) Code of Practice on behalf of the 999/112 Liaison Committee. The Liaison Committee is the primary governing body responsible for the technical and operational oversight of the UK's Public Emergency Call Service.”

Source location

Response from Department for Science, Innovation and Technology
Page 1 · response
Published 21 May 2026

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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

BT and emergency services develop and implement the detailed operational policies and processes for handling emergency calls.

Verbatim wording from the response

“The Code of Practice is not a formal policy statement, but provides guidance to organisations on the handling of 999/112 public emergency telephone calls between the Call Handling Agents and the Emergency Authorities in the UK. The detailed operational policies and processes set out within the Code are developed and implemented by BT, as the call handling agent, and the emergency services, drawing on their operational expertise. We work with these partners to bring forward agreed updates to the PECS and ensure that changes are formally reflected and applied consistently across the emergency call system.”

Source location

Response from Department for Science, Innovation and Technology
Page 1 · response
Published 21 May 2026

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

Operational partners decide whether the proposed change should be adopted into standard practice.

Verbatim wording from the response

“We coordinate closely with emergency service organisations and BT, as the 999 call handling agent, to ensure that the Code of Practice reflects agreed operational practice and supports the prioritisation of life-saving interventions. Following receipt of your report, we have engaged with the relevant operational partners who can advise on the proposal (BT, ambulance services, and policing, including through the 999 Liaison Committee and consultation with the National Police Chiefs' Council (NPCC)) to consider the issues raised and decide whether the proposed change”

Source location

Response from Department for Science, Innovation and Technology
Page 1 · response
Published 21 May 2026

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

Policing cannot unilaterally change BT routing practices or default routing rules because PECS amendments require multi-agency agreement.

Verbatim wording from the response

“For completeness, it may be helpful to note that changes to BT call handler practice or default routing rules require multi-agency agreement and formal amendment to PECS, and cannot be directed unilaterally by policing. Similarly, UK policing does not consider it safe or appropriate for police or BT call handlers to undertake enhanced clinical triage, as this risks further delay and unintended harm.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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 and BT call handlers will not undertake enhanced clinical triage because it risks further delay and unintended harm.

Verbatim wording from the response

“For completeness, it may be helpful to note that changes to BT call handler practice or default routing rules require multi-agency agreement and formal amendment to PECS, and cannot be directed unilaterally by policing. Similarly, UK policing does not consider it safe or appropriate for police or BT call handlers to undertake enhanced clinical triage, as this risks further delay and unintended harm.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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

Responsibility for developing and adopting rapid call-transfer functionality does not sit with policing.

Verbatim wording from the response

“Policing also supports the continued development of technical solutions, such as onward call connect or rapid call transfer functionality, which would enable emergency calls to be transferred swiftly between police and ambulance services when initial mis-routing is identified, without requiring the caller to re-dial. Although responsibility for such functionality does not sit with policing, we are actively supporting its development and adoption where available.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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

    Explore with policing leads and partners opportunities for clearer public messaging promoting urgent medical assistance when life may remain.

    Stated by UK policingStated plannedThe respondent said that this action was planned when they made their response on 21 May 2026.

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

Explore with policing leads and partners opportunities for clearer public messaging promoting urgent medical assistance when life may remain.

Verbatim wording from the response

“We also recognise that public understanding of how to respond in these circumstances forms part of the wider system context. The way in which online search engines and digital assistants present guidance to the public may influence which emergency service is requested in moments of acute distress. While this is a complex, multi-agency issue beyond the scope of this specific response, UK policing will explore with policing digital leads and partners whether there are opportunities to work collectively with health services and digital platforms to promote clearer public messaging that reinforces the primacy of seeking urgent medical assistance where life may still be present.”

Source location

Response from Essex Police
Page 2 · response
Published 21 May 2026

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