PFD report

Olive Nutt · Prevention of Future Deaths report

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Issued 12 Jun 2018•Inner West 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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised2

  1. Failure to return calls within pre-set time guidelines to obtain further medical details
    Part of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires it
  2. Failure to make relevant and proper notes of reported symptoms
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.8

  1. Action

    Deliver refresher training for Control Services staff on call handling and MPDS application, including an anonymised learning-from-experience case study.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
  2. Action

    Submit LAS data to the national review of ambulance response priorities, call-backs and safe systems to support improvement and learning.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
  3. Action

    Run a specific Clinical Hub recruitment programme to increase the pool of staff trained in Manchester Triage System and Clinical Hub procedures.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The national review of ambulance response times and safe call-back systems is led by the Association of Ambulance Chief Executives.

    Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to return calls within pre-set time guidelines to obtain further medical details

Wider context from the report

“2) The LAS breached its own pre-set time guidelines in failing to return a call to the deceased’s home to take further details of her medical conditions. ”

Is this part of a recurring concern?

Yes — Failure to reliably telephone patients when follow-up or assessment requires it.

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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 make relevant and proper notes of reported symptoms

Wider context from the report

“1) The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Deliver refresher training for Control Services staff on call handling and MPDS application, including an anonymised learning-from-experience case study.

Verbatim wording from the response

“In addition, our most recent Core Skills Refresher course for Control Services staff which began on 2nd August 2018 and will run until the end of March 2019, includes refresher training on call handling and the application of the MPDS protocol. This refresher course will also specifically include an anonymised case study of the issues highlighted in the management of CAD 3620 as a ‘learning from experience’ example. All EMD staff are required to attend the CSR and this case study is designed to provide EMDs with an example of best practice in applying the appropriate protocols when faced with this type of situation, to improve service delivery to patients.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 September 2018

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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

Submit LAS data to the national review of ambulance response priorities, call-backs and safe systems to support improvement and learning.

Verbatim wording from the response

“Ambulance Response Times”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 4 · response
Published 23 September 2018

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

Run a specific Clinical Hub recruitment programme to increase the pool of staff trained in Manchester Triage System and Clinical Hub procedures.

Verbatim wording from the response

“All staff working on the Clinical Hub are fully trained in the Manchester Triage System and they must undertake a minimum of one shift per month on the Clinical Hub to maintain their licence.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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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

Introduce three additional Clinical Hubs in Kenton, Barking and Croydon to increase flexible Clinical Hub staffing capacity.

Verbatim wording from the response

“Expansion of the LAS Clinical Hub”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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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

Continue the operational staff recruitment drive to increase available staffing capacity.

Verbatim wording from the response

“The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester Triage System and with specific Clinical Hub training.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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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

Secure funding for additional recruitment to address Clinical Hub and operational staffing pressures.

Verbatim wording from the response

“Resourcing is an ongoing challenge for LAS and we continue to work to address this, including securing funding for additional recruitment. I am very sorry that these difficulties resulted in a delay in ringing back Mrs Nutt to undertake a telephone assessment in a timely way.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 September 2018

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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

Reassess minimum Clinical Hub staffing levels in light of the new national response standard and increased demand.

Verbatim wording from the response

“For a day shift the minimum staffing level on the Clinical Hub is eleven members of staff, the level set by a matrix devised in 2013. Work is currently being undertaken to reassess the minimum staff levels in light of the changes within the new national response standard (ARP) and given that demand on the service has continued to increase since 2013.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 September 2018

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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

Introduce a further Clinical Hub in New Malden to expand local Clinical Hub coverage.

Verbatim wording from the response

“We are also planning to introduce a further Clinical Hub in New Malden by the end of 2020. This will be a total of six Clinical Hubs for LAS with a view to covering each of our operational sectors.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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 national review of ambulance response times and safe call-back systems is led by the Association of Ambulance Chief Executives.

Verbatim wording from the response

“I understand you expressed an interest in the response times assigned to call priorities. A national review is currently being undertaken, led by the Association of Ambulance Chief Executives (AACE) in the process of ringing back patients and safe systems and LAS will respond to any actions and outcomes from this. LAS are playing a significant role in this national review by submitting our data which is being used, in conjunction with other ambulance services, to identify areas for improvement and learning and also to identify and promote areas of good practice.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 4 · response
Published 23 September 2018

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.3

  1. 1

    Introduce the new Adastra version to expand clinicians’ access to linked patient records and improve consistency in care decisions.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
  2. 2

    Disseminate the documented delay-recording practice through regular Clinical Hub learning-from-experience updates.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
  3. 3

    Include the documented delay-recording practice in the next Manchester Triage System update for Clinical Hub clinicians.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.

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 the new Adastra version to expand clinicians’ access to linked patient records and improve consistency in care decisions.

Verbatim wording from the response

“Improvements in accessing patient medical history”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Disseminate the documented delay-recording practice through regular Clinical Hub learning-from-experience updates.

Verbatim wording from the response

“Of note, evidence of good practice was demonstrated by the clinician on the Clinical Hub on this occasion in that she made a note on the log of the reason for the delay in ringing back Mrs Nutt. It is not mandatory to do this but it is recognised that to record this information is very helpful and enables other staff members to see where an issue has arisen and the cause of it.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Include the documented delay-recording practice in the next Manchester Triage System update for Clinical Hub clinicians.

Verbatim wording from the response

“Of note, evidence of good practice was demonstrated by the clinician on the Clinical Hub on this occasion in that she made a note on the log of the reason for the delay in ringing back Mrs Nutt. It is not mandatory to do this but it is recognised that to record this information is very helpful and enables other staff members to see where an issue has arisen and the cause of it.”

Source location

2018-0233-Response-by-London-Ambulance-Service-NHS-Trust
Page 3 · response
Published 23 September 2018

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