Jean LANGAN · Prevention of Future Deaths report

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Issued 13 Dec 2024•Devon, Plymouth and Torbay

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.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
15

Described in responses

Recipients and published 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.

Concerns raised3

  1. Failure to ascertain relevant manager contact details for hospital helicopter landing sites
  2. Hazard to people on the ground near hospital helicopter landing sites
  3. Lack of a real-time database of hospital helicopter landing sites

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. Department of Health and Social Care

    Engage with NHS England and the Department for Transport to determine how to implement a fit-for-purpose real-time hospital helicopter landing-site database.

  2. Department of Health and Social Care

    Work with NHS England to deliver the requested helicopter-operations information and safety measures, including procedures, operations-manual updates, and CAA course engagement.

  3. Department of Health and Social Care

    Identify and supply a named accountable manager for each NHS Trust hospital helicopter landing site.

  4. Department for Transport

    Develop options for a comprehensive, dynamic database of hospital helicopter landing sites.

  5. Department for Transport

    Consider legislating to strengthen safety oversight of hospital helicopter landing sites.

  6. Sandwell and West Birmingham Hospitals NHS Trust

    Disseminate the EMRT policy update through safety alerts, staff bulletins, governance meetings and clinical management channels.

  7. Sandwell and West Birmingham Hospitals NHS Trust

    Implement ward-based swallowing safety cascade training, with trained cascade trainers across emergency admission routes.

  8. Sandwell and West Birmingham Hospitals NHS Trust

    Recirculate and publish the dysphagia guideline on the policy platform for access by clinical staff.

  9. Sandwell and West Birmingham Hospitals NHS Trust

    Amend and publish the EMRT policy to clarify when emergency response is appropriate despite a DNACPR decision.

  10. Sandwell and West Birmingham Hospitals NHS Trust

    Provide swallowing-awareness training to emergency-department nursing and healthcare-assistant staff.

  11. Sandwell and West Birmingham Hospitals NHS Trust

    Make online swallowing-assessment training available to all staff.

  12. Sandwell and West Birmingham Hospitals NHS Trust

    Align EMRT and Treatment Escalation Plan policy wording to provide consistent language and reduce staff confusion.

  13. Sandwell and West Birmingham Hospitals NHS Trust

    Deliver swallowing-safety training through the junior doctor induction programme for each intake.

  14. Sandwell and West Birmingham Hospitals NHS Trust

    Circulate a safety bulletin on swallowing and nutritional assessment.

  15. Sandwell and West Birmingham Hospitals NHS Trust

    Highlight the updated EMRT policy to Senior Leaders at the scheduled Risk and Assurance Group meeting.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Department of Health and Social Care

    NHS England is responsible for ensuring hospital helicopter landing sites meet applicable CAP 1264 requirements.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Department of Health and Social Care

    Enforcement of hospital helicopter landing-site safety falls beyond DHSC’s limited role.

    Outside remitThe respondent said that this matter was outside its role or authority.
  3. Department for Transport

    Oversight of HHLS safety falls outside the remit for unlicensed sites, because the Department oversees only licensed helipads.

    Outside remitThe respondent said that this matter was outside its role or authority.
  4. Department for Transport

    DHSC, working with NHS England and national health authorities, is responsible for ensuring each HHLS has an accountable manager.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  5. Department for Transport

    Hospitals are responsible for procuring and maintaining the HHLS database.

    Redirects 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 ascertain relevant manager contact details for hospital helicopter landing sites

Wider context from the report

“Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site. There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters. There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters. More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024. ”

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

Hazard to people on the ground near hospital helicopter landing sites

Wider context from the report

“Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site. There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters. There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters. More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024. ”

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 a real-time database of hospital helicopter landing sites

Wider context from the report

“Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site. There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters. There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters. More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024. ”

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

Engage with NHS England and the Department for Transport to determine how to implement a fit-for-purpose real-time hospital helicopter landing-site database.

Verbatim wording from the response

“DHSC has carefully considered your report and its recommendation to develop a database of HHLSs. We are engaging with NHS England and the Department of Transport to determine how best to implement this recommendation and ensure a database is fit for purpose. Turning to your recommendation to ensure each HHLS has an accountable manager, we agree a named accountable manager is essential for the safe running of HHLS and NHS England now have this information for all Trusts. As of the 31 January 2025 a named accountable manager has been identified and supplied, this is essential to the establishment and maintenance of an HHLS database.”

Source location

Response from DHSC
Page 2 · response
Published 6 February 2025

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

Work with NHS England to deliver the requested helicopter-operations information and safety measures, including procedures, operations-manual updates, and CAA course engagement.

Verbatim wording from the response

“2) Copies of all Standard Operating Procedures as they exist now insofar as they relate to helicopter operations.”

Source location

Response from DHSC
Page 1 · response
Published 6 February 2025

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

Identify and supply a named accountable manager for each NHS Trust hospital helicopter landing site.

Verbatim wording from the response

“DHSC has carefully considered your report and its recommendation to develop a database of HHLSs. We are engaging with NHS England and the Department of Transport to determine how best to implement this recommendation and ensure a database is fit for purpose. Turning to your recommendation to ensure each HHLS has an accountable manager, we agree a named accountable manager is essential for the safe running of HHLS and NHS England now have this information for all Trusts. As of the 31 January 2025 a named accountable manager has been identified and supplied, this is essential to the establishment and maintenance of an HHLS database.”

Source location

Response from DHSC
Page 2 · response
Published 6 February 2025

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 options for a comprehensive, dynamic database of hospital helicopter landing sites.

Verbatim wording from the response

“The DfT has carefully considered your report and its recommendation to develop a database of HHLSs. It is the responsibility of hospitals to procure and maintain any database. We will assist DHSC, hospitals and the NHS by developing options for a database that meet your and the AAIB’s recommendations. We have already started this work. DfT is the co-chair of the Onshore Leadership Group (OnSLG), a forum of rotary operators including air ambulances, Bristol Helicopters and utility operators. This has helped us to investigate how a dynamic and comprehensive database of all HHLSs can be established. We have also spoken to the supplier of the offshore helipad database, and the existing supplier of mapping software to much of the air ambulance and SAR communities.”

Source location

Response from Department for Transport
Page 2 · response
Published 6 February 2025

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

Consider legislating to strengthen safety oversight of hospital helicopter landing sites.

Verbatim wording from the response

“However, we are determined to play our part in reducing the risk at these sites as far as possible. We are also acting on the AAIB’s recommendation to strengthen oversight of HHLSs. In conjunction with the CAA and industry, the DfT is currently considering whether to legislate to ensure safety at all HHLSs. This would be a long-term (2-4 year) project requiring secondary legislation.”

Source location

Response from Department for Transport
Page 2 · response
Published 6 February 2025

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 EMRT policy update through safety alerts, staff bulletins, governance meetings and clinical management channels.

Verbatim wording from the response

“• The policy update has been communicated to Senior Leaders, Governance and Safety leads and team leader/ward management within the Clinical Directorates via weekly clinical directorate governance meetings and at the monthly Patient Safety Oversight Meeting to ensure effective dissemination of the updates”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 1 · response
Published 6 February 2025

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

Implement ward-based swallowing safety cascade training, with trained cascade trainers across emergency admission routes.

Verbatim wording from the response

“• Commenced a cascade training programme to have swallowing safety cascade trainers for each ward area, who are responsible for training their ward teams. To date 44 nurses have been trained in this role.”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Recirculate and publish the dysphagia guideline on the policy platform for access by clinical staff.

Verbatim wording from the response

“• Dysphagia guideline has been re-circulated to all clinical directorates”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Amend and publish the EMRT policy to clarify when emergency response is appropriate despite a DNACPR decision.

Verbatim wording from the response

“• Amended the Emergency Medical Response Team (EMRT) policy to clarify that EMRT calls are appropriate when there is an immediate/recoverable/un-expected event such as choking or airway compromise – even when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is in place”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 1 · response
Published 6 February 2025

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

Provide swallowing-awareness training to emergency-department nursing and healthcare-assistant staff.

Verbatim wording from the response

“• 80% of nursing and HCA staff in our ED department have received AT LEAST one form of direct training in swallowing awareness”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Make online swallowing-assessment training available to all staff.

Verbatim wording from the response

“• Online training available to all staff for swallowing assessment”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Align EMRT and Treatment Escalation Plan policy wording to provide consistent language and reduce staff confusion.

Verbatim wording from the response

“• An exercise to align the wording within the EMRT policy and the Treatment Escalation Plan policy has been undertaken to provide consistency in language across both policies to reduce confusion for staff and reinforce the required message to staff”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Deliver swallowing-safety training through the junior doctor induction programme for each intake.

Verbatim wording from the response

“• We deliver training on the new junior doctor induction programme bi-annually (each intake)”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Circulate a safety bulletin on swallowing and nutritional assessment.

Verbatim wording from the response

“• Swallowing assessment/Nutritional assessment is the topic of a planned safety bulletin to be circulated in December”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 2 · response
Published 6 February 2025

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

Highlight the updated EMRT policy to Senior Leaders at the scheduled Risk and Assurance Group meeting.

Verbatim wording from the response

“• It is planned to highlight the updated policy to Senior Leaders within the Risk and Assurance Group scheduled for 15th December 2025”

Source location

Response from Sandwell and Birmingham West NHS Trust
Page 1 · response
Published 6 February 2025

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 England is responsible for ensuring hospital helicopter landing sites meet applicable CAP 1264 requirements.

Verbatim wording from the response

“NHS England expects NHS trusts to follow the CAP1264 guidance. Through work they are undertaking to address the points set out above (and in Bristol’s letter of 6 December) NHS England will ensure that HHLS meet the CAP 1264 requirements, as appropriate.”

Source location

Response from DHSC
Page 2 · response
Published 6 February 2025

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 of hospital helicopter landing-site safety falls beyond DHSC’s limited role.

Verbatim wording from the response

“We will learn from this tragic event and will take action to help mitigate the risk posed to members of the public, staff, and flight crew at hospital helicopter landing sites (HHLSs) across the UK. DHSC has a limited role in enforcing HHLS safety.”

Source location

Response from DHSC
Page 2 · response
Published 6 February 2025

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

Oversight of HHLS safety falls outside the remit for unlicensed sites, because the Department oversees only licensed helipads.

Verbatim wording from the response

“Hospitals are responsible for the safety of HHLSs located on their grounds. The DfT is responsible for overseeing the safety only of licenced helipads. Currently, all HHLSs are unlicensed. This means they do not have to comply with CAA’s CAP 1264 guidance for hospital helicopter landing areas.”

Source location

Response from Department for Transport
Page 1 · response
Published 6 February 2025

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

DHSC, working with NHS England and national health authorities, is responsible for ensuring each HHLS has an accountable manager.

Verbatim wording from the response

“We understand that the Department of Health and Social Care (DHSC) will respond on your recommendation to ensure each HHLS has an accountable manager. We also understand that DHSC will work with NHS England to implement the demands in Bristol’s letter of 6th December 2024. A named accountable manager is essential to the establishment and maintenance of an HHLS database, and the DHSC is working with national health authorities to ensure that each HHLS has a named and competent accountable manager.”

Source location

Response from Department for Transport
Page 2 · response
Published 6 February 2025

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

Hospitals are responsible for procuring and maintaining the HHLS database.

Verbatim wording from the response

“The DfT has carefully considered your report and its recommendation to develop a database of HHLSs. It is the responsibility of hospitals to procure and maintain any database. We will assist DHSC, hospitals and the NHS by developing options for a database that meet your and the AAIB’s recommendations. We have already started this work. DfT is the co-chair of the Onshore Leadership Group (OnSLG), a forum of rotary operators including air ambulances, Bristol Helicopters and utility operators. This has helped us to investigate how a dynamic and comprehensive database of all HHLSs can be established. We have also spoken to the supplier of the offshore helipad database, and the existing supplier of mapping software to much of the air ambulance and SAR communities.”

Source location

Response from Department for Transport
Page 2 · response
Published 6 February 2025

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