PFD report

STEVE MARTIN BRIAN COOKE · Prevention of Future Deaths report

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Issued 8 Aug 2021•Mid Kent and Medway

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised4

  1. Failure to establish and verify the correct address during emergency call handling
    Part of recurring concern: Failure to locate patients requiring assessmentPart of recurring concern: Unsafe emergency call handling
  2. Failure to escalate when an unwell patient cannot be located
    Part of recurring concern: Failure to take timely escalation action when safety thresholds are breached
  3. Failure to review the original emergency call recording to establish the correct address
    Part of recurring concern: Unsafe emergency call handling
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

    Implement the 111-service requirement for callers to provide and confirm the ambulance address through an Operational Bulletin.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2021.
  2. Action

    Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2021.

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 establish and verify the correct address during emergency call handling

Wider context from the report

“Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

Is this part of a recurring concern?

Yes — Failure to locate patients requiring assessment; 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

Failure to escalate when an unwell patient cannot be located

Wider context from the report

“Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached.

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

Failure to review the original emergency call recording to establish the correct address

Wider context from the report

“Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

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

Failure to conduct an adequate location-finding follow-up call

Wider context from the report

“Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

Is this part of a recurring concern?

Yes — Failure to reliably telephone patients when follow-up or assessment requires it.

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

Implement the 111-service requirement for callers to provide and confirm the ambulance address through an Operational Bulletin.

Verbatim wording from the response

“It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.”

Source location

2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
Page 1 · response
Published 12 August 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

Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.

Verbatim wording from the response

“2. Our process upon a patient not being found by crew on scene”

Source location

2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
Page 2 · response
Published 12 August 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