PFD report

Yusuf ABDISMAD · Prevention of Future Deaths report

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Issued 27 May 2015•Inner North 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.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised3

  1. Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Failure to reliably respond to patient breathing emergenciesPart of recurring concern: Unreliable decisions about when ambulance attendance is requiredPart of recurring concern: Unsafe emergency call handling
  2. Failure to use a clear method for establishing whether a patient is conscious or unconscious
    Part of recurring concern: Failure to reliably recognise and assess unconsciousnessPart of recurring concern: Unreliable Medical Priority Dispatch System emergency assessment and advice pathways
  3. Insufficient training of 111 call handlers in recognising agonal breathing
    Part of recurring concern: Failure to ensure NHS 111 health advisors are competent for safe clinical triagePart of recurring concern: Failure to recognise agonal breathing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance

Wider context from the report

“During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Failure to reliably respond to patient breathing emergencies; Unreliable decisions about when ambulance attendance is required; Unsafe emergency call handling.

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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 a clear method for establishing whether a patient is conscious or unconscious

Wider context from the report

“In attempting to gain an answer to the question, “Is the patient awake (conscious)?”, the emergency medical dispatcher first asked “Is Yusuf awake?” When Yusuf’s mother replied “no”, the EMD went on to ask “Is he conscious?” This seems a confusing way of approaching this very important question. If a person is asleep, then one cannot know if they are conscious without waking them. If the answer to the question “Is he awake?” is “no”, then the most obvious follow up to that would appear to be, “Can you wake him?” Yusuf’s mother was by now panicking and erroneously replied “yes” to the question of whether Yusuf was conscious, though she had not tried to wake him. The EMD assumed that Yusuf was asleep but rousable, which in fact is unlikely to have been the case. There were other difficulties with the call, such as the EMD’s failure to recognise that a description of scratches all over might actually refer to a rash, missing the description of pupils no longer visible, and not thinking about the possibility of meningitis. These have, I was told at inquest, been addressed by training, but I remain concerned that such a method of attempting to elicit whether the patient is conscious or unconscious might be used by other EMDs. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and assess unconsciousness; Unreliable Medical Priority Dispatch System emergency assessment and advice pathways.

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

Insufficient training of 111 call handlers in recognising agonal breathing

Wider context from the report

“During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”

Is this part of a recurring concern?

Yes — Failure to ensure NHS 111 health advisors are competent for safe clinical triage; Failure to recognise agonal breathing.

Open source report
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Data last updated 7 September 2026