Sarah Fernyhough · Prevention of Future Deaths report

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Issued 16 Oct 2020•Essex

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.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
4

Described in 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.

Report evidence summary

Concerns raised3

  1. Automatic categorisation of abandoned calls as category 3
    Part of recurring concern: Unreliable ambulance call triage and re-triagePart of recurring concern: Unsafe emergency call handling
  2. A ceiling of category 3 for categorisation of all reported medical conditions
  3. Failure to provide call recordings or full medical information to categorisation decision-makers
    Part of recurring concern: Unsafe emergency call handling

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. East of England Ambulance Service NHS Trust

    Distribute the Regulation 28 report to the four organisations named in it.

  2. East of England Ambulance Service NHS Trust

    Review the process for abandoned calls, including calls involving potential mental health concerns.

  3. East of England Ambulance Service NHS Trust

    Develop, approve and release an abandoned-call procedure covering Category 2 escalation and mandatory Duty Manager checks, including call-recording review.

  4. East of England Ambulance Service NHS Trust

    Introduce and revise the mental health abandoned-call procedure to guide Category 2 responses for patients actively at risk.

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

Automatic categorisation of abandoned calls as category 3

Wider context from the report

“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance call triage and re-triage; 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

A ceiling of category 3 for categorisation of all reported medical conditions

Wider context from the report

“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”

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 provide call recordings or full medical information to categorisation decision-makers

Wider context from the report

“1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as category 3 A review of this practice is required. 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3 3. In the situation leading up to Ms Fernyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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

Distribute the Regulation 28 report to the four organisations named in it.

Verbatim wording from the response

“I can confirm we have distributed the report to the four organisations named in the report as per your request. AACE have confirmed they have reviewed the Trust’s response and we are awaiting feedback from the other groups.”

Source location

2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
Page 1 · response
Published 23 November 2020

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

Review the process for abandoned calls, including calls involving potential mental health concerns.

Verbatim wording from the response

“The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven’t been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call.”

Source location

2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
Page 1 · response
Published 23 November 2020

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

Develop, approve and release an abandoned-call procedure covering Category 2 escalation and mandatory Duty Manager checks, including call-recording review.

Verbatim wording from the response

“There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust’s governance and approval process. This will be completed and released in December 2020. Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include:”

Source location

2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
Page 1 · response
Published 23 November 2020

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

Introduce and revise the mental health abandoned-call procedure to guide Category 2 responses for patients actively at risk.

Verbatim wording from the response

“The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven’t been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call.”

Source location

2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf
Page 1 · response
Published 23 November 2020

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

Official responses located
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Data last updated 7 September 2026