PFD report

Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report

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Issued 18 Mar 2015•County Durham and Darlington

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
8

Described in 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.

Report evidence summary

Concerns raised3

  1. Inadequate cross-boundary emergency call routing and inter-service dispatch systems
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Unsafe emergency call handling
  2. Failure to record key information during emergency call handling
    Part of recurring concern: Unsafe emergency call handling
  3. Failure of emergency call location systems to accurately locate incidents
    Part of recurring concern: Unreliable emergency access arrangements for respondersPart 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.8

  1. Action

    Review the feasibility of increasing Gazetteer and map update frequency.

    Stated by North East Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2015.
  2. Action

    Review cross-border incident processes and systems.

    Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2015.
  3. Action

    Review call-handling procedures, identify gaps, and act on them.

    Stated by North East Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2015.

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

  1. Position

    Existing call-handling procedures are considered robust, although they will be reviewed to identify and address any gaps.

    Stated by North East Ambulance Service NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Inadequate cross-boundary emergency call routing and inter-service dispatch systems

Wider context from the report

“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Unsafe emergency call handling.

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 record key information during emergency call handling

Wider context from the report

“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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 of emergency call location systems to accurately locate incidents

Wider context from the report

“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access arrangements for responders; Unsafe emergency call handling.

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 feasibility of increasing Gazetteer and map update frequency.

Verbatim wording from the response

“The Trust uses northings and eastings co-ordinates to map the location of calls alongside a Gazetteer pulling addresses from telephone landlines. Currently it is being reviewed as to the feasibility of increasing the frequency of Gazetteer and map updates for all Ambulance Trusts.”

Source location

2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 2015

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 cross-border incident processes and systems.

Verbatim wording from the response

“Following from the Regulation 28 report and recommendations sent to Yorkshire Ambulance Service and providing emergency services, I can confirm that the North East Ambulance Service has undertaken a review of our own processes and systems in respect of cross-border incidents.”

Source location

2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 2015

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 call-handling procedures, identify gaps, and act on them.

Verbatim wording from the response

“All relevant information has been passed to our training department to review our call handling procedures and ensure any gaps are identified and acted on. We are however confident that the existing procedures are robust.”

Source location

2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015

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

Discuss with the mobilising-system supplier how to deliver Direct Electronic Incident Transfer functionality.

Verbatim wording from the response

“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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 call-handling procedures for adjoining police and ambulance services and update direct control-room telephone access numbers.

Verbatim wording from the response

“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Introduce a mobilising and communications system with integral caller-location mapping in the emergency control room.

Verbatim wording from the response

“1 Inability to Dispatch Resources without Identifying Exact Location on Mapping System In December 2014 CDDFRS introduced a new state of the art mobilising and communications system into their emergency control room. Prior to the introduction of this system control personnel would extract incident location information from callers using interrogation techniques given to them during initial training and induction.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015

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 policies and procedures for liaising with adjoining emergency services when incidents occur on or near service borders.

Verbatim wording from the response

“Following the Regulation 28 Report to Yorkshire Ambulance Service dated 19 March 2015, County Durham and Darlington Fire and Rescue Service (CDDFRS) have conducted a review of policies and procedures for liaising with the other border Blue Light Services when incidents occur on or near those adjoining borders.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015

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

Send adjoining police forces and ambulance trusts letters explaining future call-processing changes.

Verbatim wording from the response

“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Existing call-handling procedures are considered robust, although they will be reviewed to identify and address any gaps.

Verbatim wording from the response

“7. Review of call handling procedures”

Source location

2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015

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

Dispatching another ambulance service’s resource is undertaken by that service following a direct mutual-aid request, not through these systems.

Verbatim wording from the response

“6. Is it not possible for one ambulance service to dispatch an ambulance from another ambulance service?”

Source location

2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015

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

Effective mutual assistance arrangements with adjoining fire services are considered sufficient despite the inability to dispatch their resources directly.

Verbatim wording from the response

“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Direct electronic incident transfer is unavailable because emergency services’ computer systems are incompatible.

Verbatim wording from the response

“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Resources cannot be directly dispatched from other fire services because their systems are disparate and resource-location protocols are absent.

Verbatim wording from the response

“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Emergency calls cannot technically be transferred directly between emergency services.

Verbatim wording from the response

“4 Transferring Calls from One Emergency Service to Another Currently it is not technically possible to transfer an emergency call from one emergency service to another. When calls are received in error for another Emergency Service, the Fire Service control room will log the call and take as many details from the caller as possible; at the same time another fire control operator will inform the relevant emergency service. Where necessary, and as appropriate, control operators will continue to speak to callers until it is known that assistance, from the attending emergency service, has arrived at the incident.”

Source location

2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015

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

Official responses located
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Data last updated 7 September 2026