PFD report

Raphael Jeffery Gill · Prevention of Future Deaths report

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Issued 27 Apr 2022•South London

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
4

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 use emergency transport for a medical emergency
    Part of recurring concern: Failure to provide timely emergency hospital conveyancePart of recurring concern: Unreliable emergency access to hospital care
  2. Failure to prevent arrest-related bias from influencing assessment of urgency
  3. Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport
    Part of recurring concern: Unreliable risk assessment and management for patient transport
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.3

  1. Action

    Share the PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2022.
  2. Action

    Review existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2022.
  3. Action

    Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2022.

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

  1. Position

    Existing JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.

    Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 use emergency transport for a medical emergency

Wider context from the report

“(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

Is this part of a recurring concern?

Yes — Failure to provide timely emergency hospital conveyance; Unreliable emergency access to hospital care.

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 prevent arrest-related bias from influencing assessment of urgency

Wider context from the report

“(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

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 ensure a suitably qualified clinician is available to provide emergency treatment during transport

Wider context from the report

“(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

Is this part of a recurring concern?

Yes — Unreliable risk assessment and management for patient transport.

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 recognise the combination of seizures and cocaine as a medical emergency

Wider context from the report

“(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency. ”

Is this part of a recurring concern?

Yes — Unreliable seizure care and management.

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

Share the PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.

Verbatim wording from the response

“Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 5 May 2022

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 existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.

Verbatim wording from the response

“The LAS recognises that the paramedic drove the ambulance to the hospital while her clinically more junior, non-registered colleague remained in the back of the ambulance attending to Mr Gill. On balance, despite Mr Gill being fully conscious, there was a history of abnormal muscle rigidity and possible seizure activity. As such, we would be of the view that the paramedic should have attended to Mr Gill in the rear of the ambulance as they would have been immediately available in the case of deterioration. As you would be aware from the documentation provided to you at the close of the inquest, the LAS has a number of guidance notices and policies around the primacy of care. In addition, there is helpful documentation from the professional regulator on this subject.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 5 May 2022

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

Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.

Verbatim wording from the response

“In terms of the LAS, we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 5 May 2022

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 JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.

Verbatim wording from the response

“Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 5 May 2022

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 care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.

Verbatim wording from the response

“Mr Gill was appropriately assessed and promptly conveyed to the local emergency department. We have considered carefully if a pre-alert call (blue lights and sirens) was required. On balance, there is no absolute indication that a pre-alert call was required. Mr Gill was fully conscious and able to walk himself into the hospital. The time from the arrival of the conveying ambulance on the scene to leaving the scene for the hospital was 18 minutes; this is rapid and, on balance, could not have been quicker. Therefore, the LAS believes that this does not reflect a lack of urgency, that the time spent on the scene was not excessive and it does not follow that the fact Mr Gill was under arrest influenced the timeliness or appropriateness of his assessment, management or of his care.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 5 May 2022

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.1

  1. 1

    Continue working with capital Emergency Departments to ensure patients are handed over and assessed promptly on arrival.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2022.

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

  1. 1

    A definitive list mandating pre-alert calls cannot be produced because its length and complexity would make daily use impracticable.

    Stated by London Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    The decision to make a pre-alert call rests with the clinicians attending the patient, rather than being mandated by a definitive central list.

    Stated by London Ambulance Service NHS TrustRedirects 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

Continue working with capital Emergency Departments to ensure patients are handed over and assessed promptly on arrival.

Verbatim wording from the response

“The LAS continues to work with Emergency Departments across the Capital to ensure patients are handed over and assessed promptly upon their arrival. On Mr Gill's arrival, I note that a handover was provided to clinical staff within the department, which included a copy of the LAS clinical record containing Mr Gill's clinical observation.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 5 May 2022

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 definitive list mandating pre-alert calls cannot be produced because its length and complexity would make daily use impracticable.

Verbatim wording from the response

“The decision to place a pre-alert call has to sit with the clinicians attending to the patient. To provide a definitive list of circumstances where a pre-alert call is mandated would produce a document of such length and complexity that its day-to-day use would be close to impossible. It would have to cover many a multitude of medical and traumatic conditions and patient presentations. Where a patient is fully conscious and has clinical observations within the medium NEWS2 risk stratification, we would hold that a pre-alert call would not be mandated. It is worth noting that pre-alert calls have to be balanced. Their overuse can adversely affect clinical safety within an Emergency Department, as they will distract from the routine assessment of patients waiting to be assessed as well there is a balance of risk to be struck around driving under emergency conditions.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 5 May 2022

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 decision to make a pre-alert call rests with the clinicians attending the patient, rather than being mandated by a definitive central list.

Verbatim wording from the response

“The decision to place a pre-alert call has to sit with the clinicians attending to the patient. To provide a definitive list of circumstances where a pre-alert call is mandated would produce a document of such length and complexity that its day-to-day use would be close to impossible. It would have to cover many a multitude of medical and traumatic conditions and patient presentations. Where a patient is fully conscious and has clinical observations within the medium NEWS2 risk stratification, we would hold that a pre-alert call would not be mandated. It is worth noting that pre-alert calls have to be balanced. Their overuse can adversely affect clinical safety within an Emergency Department, as they will distract from the routine assessment of patients waiting to be assessed as well there is a balance of risk to be struck around driving under emergency conditions.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 5 May 2022

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