PFD report

Olive JOHNSON · Prevention of Future Deaths report

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Issued 24 Jan 2019•Lincolnshire

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. Insufficient conveying resources to meet response targets
  2. Failure to include time from the initial call to regrading in response-time measurement
    Part of recurring concern: Unreliable ambulance response-time standards and prioritisationPart of recurring concern: Unreliable emergency-service incident grading and response-time coordinationPart of recurring concern: Unreliable measurement of ambulance response times
  3. Failure to meet response times
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Unreliable emergency-service incident grading and response-time coordination
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

    Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.

    Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
  2. Action

    Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.

    Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.

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

  1. Position

    The available Community First Responder could not attend because excessive travel distance fell outside the role’s intended community coverage.

    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

Insufficient conveying resources to meet response targets

Wider context from the report

“d) Do EMAS believe they have enough conveying resources to meet their response targets? ”

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

Failure to include time from the initial call to regrading in response-time measurement

Wider context from the report

“c) Is it fair that if a patient is regarded whilst awaiting an initial response the total time from the initial call to the regrading is cancelled out? ”

Is this part of a recurring concern?

Yes — Unreliable ambulance response-time standards and prioritisation; Unreliable emergency-service incident grading and response-time coordination; Unreliable measurement of ambulance response times.

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 meet response times

Wider context from the report

“b) How many occasions have EMAS exceeded their response times since 01/01/2108 to date? ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Unreliable emergency-service incident grading and response-time coordination.

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 call out first responders

Wider context from the report

“a) Why were no first responder's called out in relation to the deceased? ”

Is this part of a recurring concern?

Yes — Unreliable Community First Responder coverage and call-out.

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

Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.

Verbatim wording from the response

“In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.”

Source location

2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 24 May 2019

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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

Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.

Verbatim wording from the response

“In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.”

Source location

2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 24 May 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

The available Community First Responder could not attend because excessive travel distance fell outside the role’s intended community coverage.

Verbatim wording from the response

“a) Why were no First Responders called out in relation to the deceased?”

Source location

2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 1 · response
Published 24 May 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

The response clock for re-categorised calls starts at regrading because this timing was decided from a national perspective.

Verbatim wording from the response

“c) Is it fair that if a patient is regraded whilst awaiting an initial response, the total time from the initial call to the regrading is cancelled out?”

Source location

2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 24 May 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