PFD report

Joan Margaret McIndoe · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 1 Jul 2020•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Lack of clarity about expectations for updates after call-centre calls to the ambulance service
    Part of recurring concern: Unreliable communication of ambulance dispatch status and expectations
  2. Failure to distinguish calls from residential facilities where contact cannot be established from calls where contact is lost during the call
    Part of recurring concern: Unreliable ambulance call triage and re-triage
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The AACE cannot mandate or instruct ambulance services, limiting its authority to require implementation of responsive safety changes.

    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 clarity about expectations for updates after call-centre calls to the ambulance service

Wider context from the report

“2. During the course of the inquest evidence was given that there is a lack of clarity about expectations for updates once a call has been placed by a call centre to the ambulance service. As a result there is no way of understanding if the position is evolving for example as in this case where the alarm kept going off and there was still no response from Mrs McIndoe. ”

Is this part of a recurring concern?

Yes — Unreliable communication of ambulance dispatch status and expectations.

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 distinguish calls from residential facilities where contact cannot be established from calls where contact is lost during the call

Wider context from the report

“1. The inquest was told that all such calls as this from residential facilities where contact cannot be established with the resident are automatically categorised as a Category 4 response by the ambulance service. This is in contrast to where a call is initiated and then contact is lost during the call. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance call triage and re-triage.

Open source report

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 AACE cannot mandate or instruct ambulance services, limiting its authority to require implementation of responsive safety changes.

Verbatim wording from the response

“The AACE provides central support and co-ordination to ambulance services to assist with implementation of national policy and the improvement of patient care. Although the AACE is not constituted to mandate or instruct ambulance services, it facilitates and enables the development of good practice. This includes consideration of concerns identified by coroners, where the AACE’s National Ambulance Medical Directors Group will discuss and disseminate learning from Prevention of Future Deaths reports. The concerns in your report have been brought to the attention of the AACE.”

Source location

2020-0138-Response-from-Dept-for-Health-and-Social-Care_Redacted.pdf
Page 1 · response
Published 30 September 2020

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

    Bring the concerns raised in the report to the Association of Ambulance Chief Executives’ attention.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 30 September 2020.
  2. 2

    Ask officials to raise the concerns with the Association of Directors of Adult Social Services and promote the benefits of contracting with certified telecare providers.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 30 September 2020.

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

Bring the concerns raised in the report to the Association of Ambulance Chief Executives’ attention.

Verbatim wording from the response

“Your report raises two matters of concern relating to interaction between telecare monitoring agencies and ambulance services and my officials have sought the advice of the Association of Ambulance Chief Executives (the AACE); NHS England and NHS Improvement (NHSEI); and the Care Quality Commission (CQC) in preparing this response.”

Source location

2020-0138-Response-from-Dept-for-Health-and-Social-Care_Redacted.pdf
Page 1 · response
Published 30 September 2020

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

Ask officials to raise the concerns with the Association of Directors of Adult Social Services and promote the benefits of contracting with certified telecare providers.

Verbatim wording from the response

“Technology enabled care providers play a vital role in supporting the independence, health and safety of older and vulnerable people and in doing so, it is essential that they can demonstrate the quality and safety of the service they operate. One way to do this is for telecare providers to apply to become certified against the Quality Standards Framework¹, overseen by TEC Quality, which has recently been accredited by the UK Accreditation Service (UKAS).”

Source location

2020-0138-Response-from-Dept-for-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 30 September 2020

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

Data last updated 7 September 2026