PFD report

Russell Curwen · Prevention of Future Deaths report

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Issued 24 Apr 2020•Lancashire and Blackburn with Darwen

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.

Report evidence summary

Concerns raised4

  1. Lack of defined and auditable determination of emergency status for courier services
  2. Lack of statutory basic, ongoing or refresher training requirements for high-powered motorcycle use and emergency exemptions
  3. Lack of traceable NHS ambulance trust control-centre coordination of vehicle allocation or dispatch
    Part of recurring concern: Unreliable ambulance dispatch and resource-allocation controls
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

    Progress commencement of section 19 and develop regulations establishing minimum driver training standards and clarifying exemptions, warning equipment rules and related best practice.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2023.
  2. Action

    Ensure the report and inquest findings are considered in developing relevant legislation and incorporated where appropriate into associated regulations and the code of best practice.

    Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 20 April 2023.

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

  1. Position

    NHS ambulance services have appropriate processes to determine emergencies and supervise lawful urgent responses, so additional measures are conditional on contrary inquest findings.

    Stated by Department for TransportExisting 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

Lack of defined and auditable determination of emergency status for courier services

Wider context from the report

“2) That there is no definition of what constitutes an emergency and in the cases of courier services no apparent auditable or co-ordinated determination of what is classified as an emergency in these cases: - In this instance it was identified that Mr Curwen was transporting blood samples for 5 patients from one hospital to another who provided for weekend cover. There does not appear to be any determination by an NHS Ambulance Trust co-ordinator or control room supervisor, or even a recorded clinical decision as to ████████ whether the situation truly requires an “emergency” response. It is not suggested at present that the samples were required for life saving treatment, or that delays could significantly reduce the life expectancy of the patients. ”

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

Lack of statutory basic, ongoing or refresher training requirements for high-powered motorcycle use and emergency exemptions

Wider context from the report

“4) That there is no statutory requirement for training: - There appears to be no statutory requirement for even a basic level of training before using high powered motorcycles and applying the exemptions or permissions, nor does there appear to be any requirement for ongoing or refresher training. ”

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

Lack of traceable NHS ambulance trust control-centre coordination of vehicle allocation or dispatch

Wider context from the report

“1) That the exemptions all relate to actions requiring an emergency response at the request of an NHS ambulance service: - There appears to be no traceable or auditable co-ordination or control of the allocation or dispatch of vehicles by a NHS ambulance trust control centre. Allocation or dispatch appears to be actioned at the request of the four NHS trusts contracted to with North West Blood Bikes under contracts for courier services; ”

Is this part of a recurring concern?

Yes — Unreliable ambulance dispatch and resource-allocation controls.

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

Lack of ongoing review of urgency and need to apply emergency exemptions or permissions

Wider context from the report

“3) That there is no auditable or co-ordinated review of the appropriateness of the urgency or emergency nature of the situation: - There does not appear to be any review of the urgency of the situation by control personnel, or continued assessment of the need to apply the exemptions or permissions referred to above. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Progress commencement of section 19 and develop regulations establishing minimum driver training standards and clarifying exemptions, warning equipment rules and related best practice.

Verbatim wording from the response

“Work is in hand to commence section 19 Road Safety Act 2006 (which will substitute section 87 Road Traffic Regulation Act 1984) to introduce a regulation-making power to mandate a minimum driver training standard before any speed exemption may be claimed. It is intended that associated regulations will also create new narrowly-defined speed limit exemption purposes and further clarify and update existing traffic sign, blue light and siren regulations.”

Source location

Response from Department for Transport
Page 2 · response
Published 20 April 2023

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

Ensure the report and inquest findings are considered in developing relevant legislation and incorporated where appropriate into associated regulations and the code of best practice.

Verbatim wording from the response

“I will ensure that this regulation 28 report, and findings from the ongoing inquest, will be considered by officials working on the relevant legislation, and where appropriate incorporated into the ongoing development of the High Speed Driver Training Regulations, Speed Limits Exemptions Regulations and Code of Best Practice under the amended Road Traffic Regulation Act 1984.”

Source location

Response from Department for Transport
Page 2 · response
Published 20 April 2023

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

NHS ambulance services have appropriate processes to determine emergencies and supervise lawful urgent responses, so additional measures are conditional on contrary inquest findings.

Verbatim wording from the response

“2) NHS Ambulance Services have the appropriate training, experience, command and control processes, and policies, to determine whether an incident is both an emergency and requiring an urgent response. Should the inquest determine any basis for suggesting that Mr. Curwen was providing a lawful response to an emergency at the request of an NHS Ambulance Service, further consideration will be given to additional guidance and amending regulations.”

Source location

Response from Department for Transport
Page 3 · response
Published 20 April 2023

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 incident indicates unlawful use of existing laws, rather than inadequacy of the current road traffic regulations.

Verbatim wording from the response

“On the information provided, this incident would appear to be one where existing laws were contravened, rather than where the existing regulations are inadequate. The fitment and use of blue lights and sirens, and the contravention of the red traffic light, all appear to be unlawful on the information provided, and neither part of providing a response to an emergency at the request of an NHS Ambulance Service nor enabled by other legislation. Established governance and oversight procedures were therefore circumvented or non-existent.”

Source location

Response from Department for Transport
Page 2 · response
Published 20 April 2023

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.2

  1. 1

    Ask the National Police Chiefs’ Council to consider developing an enforcement strategy addressing unlawful use of emergency warning equipment.

    Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 20 April 2023.
  2. 2

    Write to the Department of Health and Social Care requesting that NHS Trusts be reminded of existing legislation.

    Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 20 April 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    NHS Blood and Transplant is responsible for resupplying hospital blood banks and is satisfied with the current legal position.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Enforcement and prosecution concerning unlawful emergency warning equipment use are matters for the police and Crown Prosecution Service.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    There are no plans to grant blood bikes or medical couriers emergency traffic exemptions because their justification, purpose, proportionality, governance and record-keeping were inadequate.

    Stated by Department for TransportNo action considered necessaryThe respondent said that no further action was needed.

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

Ask the National Police Chiefs’ Council to consider developing an enforcement strategy addressing unlawful use of emergency warning equipment.

Verbatim wording from the response

“I will write to the Department for Health and Social Care, to ask that NHS Trusts are reminded of the existing legislation. I will also ask the National Police Chief’s Council to consider developing a specific enforcement strategy to counter unlawful use of emergency warning equipment.”

Source location

Response from Department for Transport
Page 2 · response
Published 20 April 2023

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

Write to the Department of Health and Social Care requesting that NHS Trusts be reminded of existing legislation.

Verbatim wording from the response

“I will write to the Department for Health and Social Care, to ask that NHS Trusts are reminded of the existing legislation. I will also ask the National Police Chief’s Council to consider developing a specific enforcement strategy to counter unlawful use of emergency warning equipment.”

Source location

Response from Department for Transport
Page 2 · response
Published 20 April 2023

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

NHS Blood and Transplant is responsible for resupplying hospital blood banks and is satisfied with the current legal position.

Verbatim wording from the response

“The Nationwide Association of Blood Bikes (NABB) did apply for exemptions under the amendments to be made to section 87 Road Traffic Act 1984 and relevant regulations by section 19 Road Safety Act 2006. The application was considered inadequate in terms of justification, primary purpose, and proportionality. In addition, their record-keeping and governance was considered inadequate. The primary role of blood bike organisations like North West Blood Bikes is to provide a free courier service to the NHS in lieu of ambulances and commercial courier companies. The responsibility of resupplying a hospital blood bank when supplies of a particular type are running low lies with NHS Blood and Transplant who have confirmed they are satisfied with the current legal position. The majority of Blood Bike groups do not purport to offer any emergency response service.”

Source location

Response from Department for Transport
Page 3 · response
Published 20 April 2023

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

Enforcement and prosecution concerning unlawful emergency warning equipment use are matters for the police and Crown Prosecution Service.

Verbatim wording from the response

“As stated above, “Blood Bikes” such as those provided by North West Blood Bikes cannot benefit from road traffic exemptions or authority to fit sirens. Their claim to the right to fit blue lights has not been tested in court and in the absence of a judgement I consider it an incorrect interpretation of the regulations. Enforcement and / or prosecution is a matter for police and the Crown Prosecution Service.”

Source location

Response from Department for Transport
Page 3 · response
Published 20 April 2023

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

There are no plans to grant blood bikes or medical couriers emergency traffic exemptions because their justification, purpose, proportionality, governance and record-keeping were inadequate.

Verbatim wording from the response

“The Nationwide Association of Blood Bikes (NABB) did apply for exemptions under the amendments to be made to section 87 Road Traffic Act 1984 and relevant regulations by section 19 Road Safety Act 2006. The application was considered inadequate in terms of justification, primary purpose, and proportionality. In addition, their record-keeping and governance was considered inadequate. The primary role of blood bike organisations like North West Blood Bikes is to provide a free courier service to the NHS in lieu of ambulances and commercial courier companies. The responsibility of resupplying a hospital blood bank when supplies of a particular type are running low lies with NHS Blood and Transplant who have confirmed they are satisfied with the current legal position. The majority of Blood Bike groups do not purport to offer any emergency response service.”

Source location

Response from Department for Transport
Page 3 · response
Published 20 April 2023

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