PFD report

Joan Alison FERGUSON · Prevention of Future Deaths report

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Issued 7 Dec 2022•Newcastle upon Tyne and North Tyneside

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
0

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

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No concerns are currently included for this report.

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

    Update and implement the bariatric and complex-patient procedure with mandatory pre-journey risk assessments, documented plans, specialist input and journey alerts.

    Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 January 2023.
  2. 2

    Monitor communication and related safety factors through adverse-incident reporting and investigation processes.

    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 30 January 2023.
  3. 3

    Strengthen internal processes to triangulate information and intelligence and improve service-user safety.

    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 30 January 2023.
  4. 4

    Share communication requirements with staff for obtaining information from patients, families, hospital staff and care partners before and during dynamic risk assessments.

    Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 January 2023.

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

  1. 1

    A dynamic risk assessment was undertaken, but its quality was fundamentally flawed by failures to obtain relevant information.

    Stated by North East Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The absence of recorded incidents was not the key factor; inadequate communication fundamentally affected the dynamic risk assessment.

    Stated by North East Ambulance Service NHS Foundation TrustDisputes 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

Update and implement the bariatric and complex-patient procedure with mandatory pre-journey risk assessments, documented plans, specialist input and journey alerts.

Verbatim wording from the response

“The ’Care and Transportation of Bariatric and Complex Patients’ procedure has been updated to provide more robust processes to prevent recurrence and strengthen the risk assessment process. This applies to those cases classified as ‘patients with complex needs and those deemed as bariatric or require complex extrication’.”

Source location

Response from North East Ambulance Services
Page 2 · response
Published 30 January 2023

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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

Monitor communication and related safety factors through adverse-incident reporting and investigation processes.

Verbatim wording from the response

“These factors and others will be monitored via our adverse incident reporting and investigation processes, equally important is the learning outcomes from such adverse events. Work is on-going to strengthen internal processes to ensure the triangulation of information and intelligence to help improve the experience, quality and safety of service services users.”

Source location

Response from North East Ambulance Services
Page 5 · response
Published 30 January 2023

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

Strengthen internal processes to triangulate information and intelligence and improve service-user safety.

Verbatim wording from the response

“These factors and others will be monitored via our adverse incident reporting and investigation processes, equally important is the learning outcomes from such adverse events. Work is on-going to strengthen internal processes to ensure the triangulation of information and intelligence to help improve the experience, quality and safety of service services users.”

Source location

Response from North East Ambulance Services
Page 5 · response
Published 30 January 2023

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

Share communication requirements with staff for obtaining information from patients, families, hospital staff and care partners before and during dynamic risk assessments.

Verbatim wording from the response

“In addition, we can confirm, as per our serious incident investigation report, that information has been shared with staff in respect to communication, before and during dynamic risk assessments.”

Source location

Response from North East Ambulance Services
Page 4 · response
Published 30 January 2023

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

A dynamic risk assessment was undertaken, but its quality was fundamentally flawed by failures to obtain relevant information.

Verbatim wording from the response

“Whilst the crew did undertake a dynamic risk assessment our own internal investigation concluded that they had not established any changes in mobility. This included not seeking information from hospital staff or the patient’s family. This fundamentally flawed the quality of the dynamic risk assessment which was therefore based on previous experience and without clear communication with the patient.”

Source location

Response from North East Ambulance Services
Page 4 · response
Published 30 January 2023

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 absence of recorded incidents was not the key factor; inadequate communication fundamentally affected the dynamic risk assessment.

Verbatim wording from the response

“In respect to the point ‘the absence of recorded incidents prevented an accurate risk assessment taking place’. Whilst we acknowledge that information regarding previous incidents is important to assist with risk assessments, it is important to draw upon the response below. The fact that our staff had not spoken with hospital staff, Joan’s family and Joan is a key factor in the effectiveness of the dynamic risk assessment. As heard during the inquest evidence provided by the Trust’s Health and Safety Manager, dynamic risk assessment was explained as “merely a thought process when things change, and you think on your feet, and you might need to change process or put a new risk control measure in place to do something safely”.”

Source location

Response from North East Ambulance Services
Page 4 · response
Published 30 January 2023

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