PFD report

Lisa CODLING · Prevention of Future Deaths report

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Issued 19 Feb 2021•Brighton and Hove

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised1

  1. Delays in ambulance response to acute overdose emergencies
    Part of recurring concern: Delays in ambulance attendance
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.3

  1. Action

    Meet NHS Pathways to share learning and progress concerns recorded on the Pathways issue log.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
  2. Action

    Discuss the case with the NHS England and NHS Improvement national clinical lead developing an overdose triage and clinical oversight framework.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
  3. Action

    Refer intentional and unintentional overdose calls to a clinician before dispatching an ambulance.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.

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

  1. Position

    Upgrading all overdoses, including paracetamol overdoses, to Category 2 is not feasible because it could adversely affect responses to confirmed life-threatening cases.

    Stated by South East Coast Ambulance Service NHS Foundation TrustUnable 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

Delays in ambulance response to acute overdose emergencies

Wider context from the report

“(1) In her email of 12th October 2020 ████████ gave (in response to my question) her reply as to why South East Coast Ambulance Service would not be conducting a Serious Incident Report. The penultimate point stated “clinicians advise that paracetamol will not kill a patient within a 3 hour timeframe although a paracetamol overdose should still be considered in time sensitive emergency.” In this case of acute overdose the ambulance service took 3 hours and 10 minutes to arrive. Too late for Ms. Codling. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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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

Meet NHS Pathways to share learning and progress concerns recorded on the Pathways issue log.

Verbatim wording from the response

“We further propose to:”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 5 · response
Published 22 February 2021

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 the case with the NHS England and NHS Improvement national clinical lead developing an overdose triage and clinical oversight framework.

Verbatim wording from the response

“Action that SECAmb has taken/proposes to take”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 4 · response
Published 22 February 2021

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

Refer intentional and unintentional overdose calls to a clinician before dispatching an ambulance.

Verbatim wording from the response

“❖ The Trust had implemented (from 1 May 2020) a process that exceeded NHS Pathways’ current requirements by referring intentional/unintentional overdose calls to a clinician; that new process was correctly followed. ❖ The Mental Health Clinician successfully negotiated with Ms Codling, who denied taking an overdose, to have an ambulance attend; without such professional negotiation it is apparent that Ms Codling, who evidently presented as possessing Mental Capacity, would have chosen to have no response. ❖ At all stages SECAmb preferred the information from Ms Codling’s partner and acted accordingly and in her best interest. ❖ Ms Codling’s partner stated that he had seen her take ████████ paracetamol tablets. This was the baseline information which would not have been a toxic overdose based on the average size of an adult female, and this was confirmed by post mortem findings.”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 2 · response
Published 22 February 2021

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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

Upgrading all overdoses, including paracetamol overdoses, to Category 2 is not feasible because it could adversely affect responses to confirmed life-threatening cases.

Verbatim wording from the response

“After careful consideration, we do not believe that it is feasible to upgrade all overdoses, including paracetamol overdose, to a C2 disposition, as this would have a deleterious effect on responses to those patients who are confirmed as requiring this level of response through presenting with a potentially life-threatening complaints.”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 5 · response
Published 22 February 2021

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

Rapid fatality after paracetamol overdose is considered extremely rare, with typical fatal toxicity progressing over days to weeks rather than hours.

Verbatim wording from the response

“Rapid death as a result of paracetamol ingestion is a very rare event. The members of our Serious Incident group, which includes a multi-professional team of consultant and other senior clinicians from medicine, paramedicine and nursing, had not witnessed or encountered this presentation. Our Medical Director and Assistant Medical Director, who are both experienced Consultants in Emergency Medicine, had not encountered any such cases, nor had their Consultant in Emergency Medicine colleagues. It is for this reason that it was stated in the Serious Incident group that patients do not die from paracetamol overdose within a three-hour timeframe. Clinicians’ experience of fatality following paracetamol overdose is a”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 3 · response
Published 22 February 2021

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.4

  1. 1

    Raise a formal issue with NHS Pathways for consideration of the matters identified at inquest.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
  2. 2

    Discuss with the Royal College of Emergency Medicine whether the issue should be flagged as a safety alert.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
  3. 3

    Meet the NHS England national ambulance team.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
  4. 4

    Bring the case to the attention of National Ambulance Service Medical Directors.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Further internal training escalation is not indicated because the presentation is rare, clinical information is limited, and training time is constrained.

    Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Existing Joint Royal Colleges Ambulance Liaison Committee guidelines and Toxbase guidance are considered sufficient, so further internal training is not required.

    Stated by South East Coast 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 respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Raise a formal issue with NHS Pathways for consideration of the matters identified at inquest.

Verbatim wording from the response

“Action that SECAmb has taken/proposes to take”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 4 · response
Published 22 February 2021

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 Royal College of Emergency Medicine whether the issue should be flagged as a safety alert.

Verbatim wording from the response

“Action that SECAmb has taken/proposes to take”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 4 · response
Published 22 February 2021

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

Meet the NHS England national ambulance team.

Verbatim wording from the response

“We further propose to:”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 5 · response
Published 22 February 2021

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

Bring the case to the attention of National Ambulance Service Medical Directors.

Verbatim wording from the response

“Action that SECAmb has taken/proposes to take”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 4 · response
Published 22 February 2021

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

Further internal training escalation is not indicated because the presentation is rare, clinical information is limited, and training time is constrained.

Verbatim wording from the response

“We have also considered whether any further internal training is indicated. Taking into account the rarity of this presentation, the very limited volume of clinical information available and the competing demands on limited training time, we have concluded that further escalation is not indicated but rather that reliance on the Joint Royal Colleges Ambulance Liaison Committee guidelines and Toxbase should continue.”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 5 · response
Published 22 February 2021

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 Joint Royal Colleges Ambulance Liaison Committee guidelines and Toxbase guidance are considered sufficient, so further internal training is not required.

Verbatim wording from the response

“We have also considered whether any further internal training is indicated. Taking into account the rarity of this presentation, the very limited volume of clinical information available and the competing demands on limited training time, we have concluded that further escalation is not indicated but rather that reliance on the Joint Royal Colleges Ambulance Liaison Committee guidelines and Toxbase should continue.”

Source location

2021-0047-Response-from-South-East-Coast-Ambulance-Service-Redacted
Page 5 · response
Published 22 February 2021

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