PFD report

Daniel Maurice McMahon · Prevention of Future Deaths report

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Issued 21 Oct 2013•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.

View original report
Concerns
4

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
2

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. Failure to identify difficulties experienced by patients on Section 17 leave
    Part of recurring concern: Unreliable mental-health patient leave arrangementsPart of recurring concern: Unsafe management of inpatient leave and absence
  2. Failure to stop trains and set signals to danger when an unwell person is trespassing on the line
    Part of recurring concern: Unreliable railway rules for stopping trains to protect people in danger
  3. Lack of clear guidance on whether lung decompression needles should be used with a valve
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.2

  1. Action

    Review the Code of Practice on section 17 leave of absence and care planning, informed by this case.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2013.
  2. Action

    Review needle chest decompression practice with an external thoracic-trauma expert and confirm the appropriateness of not using one-way valves.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2013.

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

  1. Position

    The London Ambulance Service is responsible for responding to the concern about its crew’s use of a decompression needle without a valve.

    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 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 identify difficulties experienced by patients on Section 17 leave

Wider context from the report

“(2) Department of Health:- Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up ”

Is this part of a recurring concern?

Yes — Unreliable mental-health patient leave arrangements; Unsafe management of inpatient leave and absence.

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 stop trains and set signals to danger when an unwell person is trespassing on the line

Wider context from the report

“(3) RSSB:- The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line. (The current position would be to set the signals to caution). ”

Is this part of a recurring concern?

Yes — Unreliable railway rules for stopping trains to protect people in danger.

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 clear guidance on whether lung decompression needles should be used with a valve

Wider context from the report

“(4) London Ambulance Service:- The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve. ”

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 gather and pass accurate trespasser and track-section location information

Wider context from the report

“(1) Metropolitan Police :- That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track. This is in addition to the attendance location and the incident location normally recorded when a 999 call is made. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information.

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

Review the Code of Practice on section 17 leave of absence and care planning, informed by this case.

Verbatim wording from the response

“We are currently reviewing the advice in the “Code of Practice Mental Health Act 1983”. This includes reviewing the chapter on leave of absence under section 17 of the Mental Health Act 1983 and the references to care planning. The experience of this case will be used to assist that review.”

Source location

2013-0271-Response
Page 2 · response
Published 19 December 2013

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 needle chest decompression practice with an external thoracic-trauma expert and confirm the appropriateness of not using one-way valves.

Verbatim wording from the response

“The report brings to my attention your concerns following the evidence of the court appointed expert in relation to the use of bilateral needle chest decompressions without a valve. As you will be aware, the LAS had available a senior paramedic prepared and able to give evidence on the issue of needle chest decompressions at the inquest but this witness was not called. The LAS have reviewed the matter and I hope that you find the following explanation helpful:”

Source location

2013-0271-Response-R
Page 1 · response
Published 19 December 2013

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 London Ambulance Service is responsible for responding to the concern about its crew’s use of a decompression needle without a valve.

Verbatim wording from the response

“I understand the London Ambulance Service will reply to you directly on your concern about their crew’s use of a decompression needle without a valve.”

Source location

2013-0271-Response
Page 1 · response
Published 19 December 2013

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 current approach of not using one-way valves for needle chest decompressions is considered appropriate.

Verbatim wording from the response

“Both before and after the inquest, this matter has been discussed at some length within the Medical Directorate of the LAS. The Medical Director of the LAS and one of our Senior Paramedics took the opportunity to review our practice with Surgeon Commander Leigh Smith, an extensively published author on needle chest decompression and expert on the management of thoracic trauma, and concluded that the current approach of the LAS (and UK ambulance services) is appropriate in respect of not using one way valves on needle chest decompressions.”

Source location

2013-0271-Response-R
Page 2 · response
Published 19 December 2013

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