PFD report

Steven David Jackson · Prevention of Future Deaths report

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Issued 2 Nov 2015•Essex

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
5

Raised in this report

Recipients
6

Named on the report

Responses found
0

Of 6 recipients

Stated actions
0

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 raised5

  1. Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
    Part of recurring concern: Failure to reliably recognise and respond to epiglottitis in adults
  2. Lack of effective training of ambulance staff on when to convey a patient to hospital
  3. Failure to learn from prior events
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 up-to-date knowledge among general practitioners about epiglottitis in adults

Wider context from the report

“1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally. He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to epiglottitis in adults.

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 effective training of ambulance staff on when to convey a patient to hospital

Wider context from the report

“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”

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 learn from prior events

Wider context from the report

“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”

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

Lack of effective training of ambulance staff in use of the sepsis screening tool

Wider context from the report

“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”

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

Ineffective use of the sepsis screening tool by ambulance staff

Wider context from the report

“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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