Joan Alison FERGUSON · Prevention of Future Deaths report

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Issued 7 Dec 2022•Newcastle upon Tyne and North Tyneside

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

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 raised0

    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. North East Ambulance Service NHS Foundation Trust

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

    2. North East Ambulance Service NHS Foundation Trust

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

    3. North East Ambulance Service NHS Foundation Trust

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

    4. North East Ambulance Service NHS Foundation Trust

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

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

    1. North East Ambulance Service NHS Foundation Trust

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

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

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

      Disputes 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

    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

    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