PFD report

Graham George Smith · Prevention of Future Deaths report

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Issued 23 May 2019•Leicester City and South Leicestershire

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 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 raised3

  1. Failure to provide senior review or red-flag warnings of heightened concern to attending crews
  2. Lack of capacity to link repeat emergency calls concerning the same patient at the same address
    Part of recurring concern: Unsafe emergency call handling
  3. Lack of a system for using linked repeat-call information to provide patient safety-netting
    Part of recurring concern: Unreliable ambulance-service computer systems for safety-critical 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.2

  1. Action

    Extend duplicate-call alert checking toward a 12-hour window while reviewing CAD feasibility and system-performance impact.

    Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 August 2019.
  2. Action

    Provide the clinical advice team with access to previous calls, attendances, summary care records and Leicester SystmOne records to inform referral and safe-discharge decisions.

    Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.

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

  1. Position

    Extending duplicate-call checking requires assurance that increased CAD processing will not detrimentally affect the system’s ability to handle incoming calls.

    Stated by East Midlands Ambulance Service NHS 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

Failure to provide senior review or red-flag warnings of heightened concern to attending crews

Wider context from the report

“It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed. It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED. ”

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 capacity to link repeat emergency calls concerning the same patient at the same address

Wider context from the report

“It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed. It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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 a system for using linked repeat-call information to provide patient safety-netting

Wider context from the report

“It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed. It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance-service computer systems for safety-critical information.

Open source report

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

Extend duplicate-call alert checking toward a 12-hour window while reviewing CAD feasibility and system-performance impact.

Verbatim wording from the response

“EMAS currently has a process in place to alert all Emergency Operations Centre (EOC) staff upon receipt of a call, that a previous call has been made from that same address, or within 50 meters of the address coordinates, within the last nine hours. This is highlighted by a yellow warning box stating “Possible Duplicate Calls” on the Computer Aided Dispatch (CAD) system.”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 August 2019

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

Provide the clinical advice team with access to previous calls, attendances, summary care records and Leicester SystmOne records to inform referral and safe-discharge decisions.

Verbatim wording from the response

“Refusal to travel – If a patient refuses transport to hospital; the attending Technician should carry out a mental capacity assessment on the patient and then contact the CAT who will speak to the patient and ensure that the refusal is made on a recorded telephone line. The patient’s signature should be gained on the Electronic Patient Report Form stating that they are refusing transport to hospital, as per the Non-Conveyance Summary Guide for Technicians.”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 3 · response
Published 2 August 2019

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

Extending duplicate-call checking requires assurance that increased CAD processing will not detrimentally affect the system’s ability to handle incoming calls.

Verbatim wording from the response

“Having received this notification, the dispatcher will check the CAD system and verbally notify the crew by radio of any previous attendance within the last nine hours. In Mr Smith’s case, however, the previous attendance was outside of this window, which at that time was only five hours. We are incrementally increasing this time to twelve hours; however we have to do this in small increments to ensure that it does not have a detrimental impact on the CAD system.”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 August 2019

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 CAT access to prior attendances, summary care records and local GP records enables informed onward-referral or safe-at-home decisions.

Verbatim wording from the response

“The CAT team has had access to all previous calls and attendances for the past three months. The team also has access to summary care records (which are an electronic record of important patient information, created from GP medical records) and in Leicester, read-only access to SystmOne (a centrally hosted clinical computer system used by GPs and other healthcare professionals in the UK). This enables the CAT clinician to be fully informed of the patient’s past medical history and any care plans which may be in place, enabling them to make an informed decision as to whether the patient requires onward referral or whether the patient can safely be left at home.”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 3 · response
Published 2 August 2019

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.3

  1. 1

    Issue supported safe-discharge clinical bulletins to frontline clinical staff and Emergency Operations Control centres.

    Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
  2. 2

    Request a review of ambulance clinical guidelines covering alcohol misuse, withdrawal, presentation and management.

    Stated by Association of Ambulance Chief Executives and National Ambulance Service Medical DirectorsStated plannedThe respondent said that this action was planned when they made their response on 2 August 2019.
  3. 3

    Publish and issue resulting guideline recommendations to ambulance clinicians through the clinical practice guideline development plan.

    Stated by Association of Ambulance Chief Executives and National Ambulance Service Medical DirectorsStated plannedThe respondent said that this action was planned when they made their response on 2 August 2019.

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

  1. 1

    Crews received information about Mr Smith’s presenting condition through dispatch messages, which the system confirmed they read.

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

    JRCALC is assigned responsibility for reviewing and recommending changes to ambulance guidelines on alcohol misuse and withdrawal management.

    Stated by Association of Ambulance Chief Executives and National Ambulance Service Medical DirectorsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 supported safe-discharge clinical bulletins to frontline clinical staff and Emergency Operations Control centres.

Verbatim wording from the response

“5. EMAS On Scene Conveyance and Referral Procedure - Non-Conveyance Guide”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 3 · response
Published 2 August 2019

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

Request a review of ambulance clinical guidelines covering alcohol misuse, withdrawal, presentation and management.

Verbatim wording from the response

“We will be taking action to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management. We will ensure that any recommendations are published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.”

Source location

2019-0167-Response-by-Associaion-of-Ambulance-Chief-Executives
Page 1 · response
Published 2 August 2019

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

Publish and issue resulting guideline recommendations to ambulance clinicians through the clinical practice guideline development plan.

Verbatim wording from the response

“We will be taking action to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management. We will ensure that any recommendations are published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.”

Source location

2019-0167-Response-by-Associaion-of-Ambulance-Chief-Executives
Page 1 · response
Published 2 August 2019

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

Crews received information about Mr Smith’s presenting condition through dispatch messages, which the system confirmed they read.

Verbatim wording from the response

“I can confirm that all crews on all attendances to Mr Smith were provided with information regarding the presenting condition of Mr Smith. This information was passed to the crews by the Dispatchers via the Mobile Data Terminal system (MDT), which is located on the dashboard of the ambulance. Our system confirms that these messages were read by the crews on the ambulances which attended Mr Smith.”

Source location

2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 2 August 2019

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

JRCALC is assigned responsibility for reviewing and recommending changes to ambulance guidelines on alcohol misuse and withdrawal management.

Verbatim wording from the response

“We will be taking action to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management. We will ensure that any recommendations are published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.”

Source location

2019-0167-Response-by-Associaion-of-Ambulance-Chief-Executives
Page 1 · response
Published 2 August 2019

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