PFD report

Jean GROVES · Prevention of Future Deaths report

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Issued 23 Jan 2026•Norfolk

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
1

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
5

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. Failure to provide emergency responders with access details for vulnerable patients
    Part of recurring concern: Failure to provide emergency responders with readily accessible safety-critical patient information
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

    Confirm procedures for recording and communicating property access information when provided.

    Stated by Careline365/Apello GroupStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  2. Action

    Consider how access arrangements should be recorded and communicated within multi-agency emergency response pathways.

    Stated by Careline365/Apello GroupStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  3. Action

    Review onboarding and data-capture processes to ensure prompts exist for recording known access arrangements.

    Stated by Careline365/Apello GroupStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Referrals without recorded access details are declined and returned to EEAST under the existing process.

    Stated by Norfolk County CouncilExisting 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

Failure to provide emergency responders with access details for vulnerable patients

Wider context from the report

“I have concerns that if emergency responders are not being provided with access details for vulnerable patients when providing support to the ambulance service under the NHS “Access to the Stack” initiative, this may lead to future deaths. ”

Is this part of a recurring concern?

Yes — Failure to provide emergency responders with readily accessible safety-critical patient information.

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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

Confirm procedures for recording and communicating property access information when provided.

Verbatim wording from the response

“As part of this review we have:”

Source location

Response from Careline365
Page 3 · response
Published 26 January 2026

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

Consider how access arrangements should be recorded and communicated within multi-agency emergency response pathways.

Verbatim wording from the response

“As part of this review we have:”

Source location

Response from Careline365
Page 3 · response
Published 26 January 2026

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 onboarding and data-capture processes to ensure prompts exist for recording known access arrangements.

Verbatim wording from the response

“As part of this review we have:”

Source location

Response from Careline365
Page 3 · response
Published 26 January 2026

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

Referrals without recorded access details are declined and returned to EEAST under the existing process.

Verbatim wording from the response

“As no access details were recorded on the system, the referral was subsequently declined and returned to EEAST. If we have no access details recorded on the A2S referral portal or the Service Users Social Care record our process is to decline the referral and return to Stack. In accordance with our usual process, details of declined referrals should be recorded on the Service User’s Social Care record. Unfortunately, in this instance, no such record was created. This was an internal recording error; it had no impact on our decision making.”

Source location

Response from Norfolk County Council
Page 1 · response
Published 26 January 2026

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 services determine how to gain property access when Careline365 has no access arrangements recorded.

Verbatim wording from the response

“Where no access arrangements are recorded, the ARC escalates the incident to the emergency services and provides all available information. The emergency services then determine how to gain access.”

Source location

Response from Careline365
Page 2 · response
Published 26 January 2026

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

The records contained no property access details, and the ARC accurately reported their absence when the ambulance service asked.

Verbatim wording from the response

“Ms Groves’ telecare account formed part of a portfolio of service users transferred to Careline365 from Saffron Housing Association during a bulk migration of monitoring services. The dataset transferred to Careline365 contained standard ARC account information, including personal details, medical information and emergency contacts where available. Subsequent review confirms that no key safe or property access details were included for Ms Groves in the migrated records and were therefore not recorded on her account.”

Source location

Response from Careline365
Page 2 · response
Published 26 January 2026

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

Careline365 does not install or control property access arrangements unless specifically requested by the service user or referring authority.

Verbatim wording from the response

“Careline 365 do not install or control property access arrangements unless specifically requested by the Service User or the referring authority, in this case Norfolk County Council.”

Source location

Response from Careline365
Page 2 · response
Published 26 January 2026

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

The ambulance service is responsible for call categorisation and decisions to refer cases through the community response pathway.

Verbatim wording from the response

“Careline365 does not operate or control the NHS “Access to the Stack” pathway. Our role was to respond to the alarm activation and escalate the incident to 999 due to the uncertainty regarding injury.”

Source location

Response from Careline365
Page 3 · response
Published 26 January 2026

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

    Issue a communication to triaging staff requiring every accepted or declined referral and all access-detail attempts to be recorded in the service user’s Liquid Logic record.

    Stated by Norfolk County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  2. 2

    Adhere strictly to the procedure for recording each referral and its reason for decline on the service user’s record.

    Stated by Norfolk County CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The missing record was an internal recording error that did not affect the referral decision.

    Stated by Norfolk County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Issue a communication to triaging staff requiring every accepted or declined referral and all access-detail attempts to be recorded in the service user’s Liquid Logic record.

Verbatim wording from the response

“To prevent a recurrence of a recording error a communication is being issued to all Operational Managers and Reablement Liaison Officers responsible for triaging incoming referrals. This will remind staff that every referral—whether accepted or declined—must be recorded on the Service User’s Liquid Logic record, and that all attempts to obtain access details must also be clearly documented to ensure a complete and transparent audit trail.”

Source location

Response from Norfolk County Council
Page 2 · response
Published 26 January 2026

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

Adhere strictly to the procedure for recording each referral and its reason for decline on the service user’s record.

Verbatim wording from the response

“The manager on duty at the time does not remember the referral. He has confirmed that he is fully aware of the correct procedure, which requires the creation of a contact on the Service User’s record outlining the referral and the reason for its decline. He acknowledges that he did not follow this process on this occasion and has assured that he will adhere to it strictly going forward.”

Source location

Response from Norfolk County Council
Page 1 · response
Published 26 January 2026

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

The missing record was an internal recording error that did not affect the referral decision.

Verbatim wording from the response

“As no access details were recorded on the system, the referral was subsequently declined and returned to EEAST. If we have no access details recorded on the A2S referral portal or the Service Users Social Care record our process is to decline the referral and return to Stack. In accordance with our usual process, details of declined referrals should be recorded on the Service User’s Social Care record. Unfortunately, in this instance, no such record was created. This was an internal recording error; it had no impact on our decision making.”

Source location

Response from Norfolk County Council
Page 1 · response
Published 26 January 2026

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