PFD report

Ashley WALKER · Prevention of Future Deaths report

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Issued 31 Jan 2020•Warwickshire

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
1

Of 1 recipient

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 raised3

  1. Unavailability of an effective antidote on ambulances
    Part of recurring concern: Failure to ensure paramedics have required emergency medicines for pre-hospital care
  2. Toxicity of the substance as a recognised method of suicide
  3. Failure to distinguish ingestion from spillage in communication
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.4

  1. Action

    Raise nationally with the NARU clinical subgroup the proposal to make methylene blue availability standard practice.

    Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  2. Action

    Remove WISER from frontline work devices and restrict its use to trained incident and hazardous-area officers.

    Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  3. Action

    Review whether HART paramedics can carry and administer methylene blue for sodium nitrate ingestion cases.

    Stated by West Midlands Ambulance Service University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.

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

Unavailability of an effective antidote on ambulances

Wider context from the report

“(2) ████████ toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance. ”

Is this part of a recurring concern?

Yes — Failure to ensure paramedics have required emergency medicines for pre-hospital care.

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

Toxicity of the substance as a recognised method of suicide

Wider context from the report

“(2) ████████ toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance. ”

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 distinguish ingestion from spillage in communication

Wider context from the report

“(1) It is apparent that a communication error confused the ingestion of ████████ with a spillage of ████████ ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Raise nationally with the NARU clinical subgroup the proposal to make methylene blue availability standard practice.

Verbatim wording from the response

“Response We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.”

Source location

Response-from-West-Midlands-Ambulance-Service
Page 1 · response
Published 8 February 2020

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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

Remove WISER from frontline work devices and restrict its use to trained incident and hazardous-area officers.

Verbatim wording from the response

“Response Following this incident we have instructed all of our staff to remove the WISER (Wireless Information System for Emergency Responders) App from all work mobile phones and tablets. The App will now only be used following triaging by Tactical Incident Commanders (TICs), the National Inter-Agency Liaison Officer (NILO) and team leaders in our Hazardous Area Response Team (HART). This is to ensure the risk of harm to both our patients and staff is reduced and to mitigate confusion at scene, as crews on scene will only be able to access advice from trained officers.”

Source location

Response-from-West-Midlands-Ambulance-Service
Page 1 · response
Published 8 February 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

Review whether HART paramedics can carry and administer methylene blue for sodium nitrate ingestion cases.

Verbatim wording from the response

“Response We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.”

Source location

Response-from-West-Midlands-Ambulance-Service
Page 1 · response
Published 8 February 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

Produce guidance for officers distinguishing clinical management of individual chemical ingestion from chemical spills.

Verbatim wording from the response

“As a Trust we have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents which highlight the clinical management differences between individual ingestion and chemical spills for all of our Officers.”

Source location

Response-from-West-Midlands-Ambulance-Service
Page 1 · response
Published 8 February 2020

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