PFD report

Sabrina Stevenson · Prevention of Future Deaths report

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Issued 30 Mar 2015•Inner North London

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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: 15
Recipients: 3
Responses found: 3
Stated actions: 36

Recipients and published responses

College of ParamedicsResponse found London Ambulance Service NHS TrustResponse found NHS EnglandResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

The investigation into the death of Sabrina Stevenson concluded at the end of the inquest on 23 January 2015. The conclusion of the inquest was narrative (Copy attached).

Circumstances of the death

Sabrina Stevenson died on 16 December 2012 from a ruptured ectopic pregnancy; she was aged 28. That morning she began to suffer from abdominal pain, diarrhoea and vomiting; she went on to suffer an episode of collapse. Her flat mate called for an ambulance at approximately 6pm.

I have set out below my findings of fact based on the evidence heard, including an independent expert opinion from Professor ████████

The initial triaging of the 999 call prompted a clinical call-back, rather than ambulance attendance; this represented an ‘under-triaging’ of Sabrina’s condition. The call-back did occur within the expected time-frame and retriaged Sabrina as requiring an ambulance to attend within 30 minutes.

Demand for ambulances was higher than had been predicted for the time of year. The individual who undertook the call-back assessment did not have access to the current response times for ambulances, which were exceeding the intended 30 minute time-frame.

A further call-back occurred after the time-frame for attendance had past; this call was not made by a clinician and did not provide sufficient safety-net advice to Sabrina. There was also no reassessment of the call categorisation, nor (in the alternative) automated recategorisation at this point.

One hour after the initial 999 call an ambulance dispatch was attempted; however, this vehicle was part of a pilot scheme which did not accept patients with diarrhoea and vomiting. As such, the dispatch request was turned down. I concluded that the pilot scheme was appropriately instituted and the non-attendance was in-line with the clinical guidance. This conclusion was in contradistinction to the ambulance Trust’s own internal investigation, which was later recanted by the Trust in evidence at the inquest.

Three further ambulances were attempted to be dispatched to Sabrina but were diverted to higher priority calls. An ambulance crew first attended Sabrina approximately two hours after the initial 999 call.

The focus of this crew was insufficient regarding the potential for serious abdominal pathology as the cause for an initial low blood pressure and raised heart rate. Hypovolaemic shock was not considered in a meaningful way and too much reliance was placed on Sabrina apparently reporting that she had a contraceptive implant in place. This was contrary to the evidence of her GP, who stated that it had previously been removed. Sabrina presented the crew with a difficult situation regarding her pain management and also the assessment of her capacity to make treatment decisions. There was no formal documented assessment of her capacity.

Sabrina suffered a further episode of collapse, which was described by the independent expert as the ‘last possible point at which it would be defensible to delay’ extraction out of the flat. A second ambulance crew was requested to assist with extraction.

There was a failure of appropriate handover to the second crew. They persisted with an inappropriate assessment focus and insufficient consideration as to whether Sabrina had lost capacity to make treatment decisions. The two crews also failed to consider extraction techniques, other than a carry chair. The independent expert set out that there was a failure either to use a system to allow the patient to be carried flat, or to have such a system available.

Sabrina subsequently suffered a catastrophic collapse whilst in the carry chair. She went into cardiac arrest and, despite rapid transport to hospital, arriving at 22.41, she was declared dead at 23.24.

I heard evidence from a Consultant Gynaecologist, based at the hospital at which Sabrina died. She stated that, had Sabrina arrived in A&E at a point prior to cardiac arrest, then, on the balance of probabilities, the ectopic pregnancy would have been diagnosed and she would rapidly have had life-saving surgery.

Coroner’s concerns

(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.

(2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall;

(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed;

(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;

(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view;

(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations. Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain. It is clear that the Trust are taking further steps to address this; however, more detailed information as to time-frames and progress in this regard are required.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised15

Variation in paramedic training
Failure to implement or consider automated call recategorisation
Part of recurring concern: Unreliable ambulance call triage and re-triage Part of recurring concern: Unsafe emergency call handling
Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues
Part of recurring concern: Inadequate staff training for managing complex care needs

Responses linked to these concerns

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

Actions described in response 27

Action
Assure delivery of the LAS Improvement Programme through the NHS England LAS Oversight Group and regular assurance of the lead commissioner.
Stated by NHS EnglandStated planned
Action
Review LAS operational performance weekly and agree additional actions to maintain resilience and improve ambulance response times.
Stated by NHS EnglandStated completed
Action
Monitor LAS ambulance response-time and utilisation performance through the LAS Contracts and Performance Group during 2015/16.
Stated by NHS EnglandStated planned

Action
Commission and complete a diagnostic review of the key operational drivers of LAS underperformance, including utilisation and vehicle-hour constraints.
Stated by NHS EnglandStated completed
Action
Reduce unnecessary multiple-vehicle dispatches through the agreed change programme.
Stated by London Ambulance Service NHS TrustStated planned
Action
Invest in new ambulance vehicles to increase operational capacity.
Stated by London Ambulance Service NHS TrustStated planned
Action
Assess the clinical appropriateness and feasibility of automated call re-categorisation.
Stated by London Ambulance Service NHS TrustStated completed
Action
Keep more ambulances operational and out of workshops through the agreed change programme.
Stated by London Ambulance Service NHS TrustStated planned
Action
Operate the updated Serious Incident Policy and Procedure with board-to-management responsibilities for reporting, investigation and recurrence-risk reduction.
Stated by London Ambulance Service NHS TrustStated completed
Action
Monitor investigation timeliness and obtain assurance that serious-incident investigations are thorough and appropriately approved.
Stated by London Ambulance Service NHS TrustStated in progress
Action
Recruit 850 staff, including approximately 150 new posts, to increase staffing and capacity.
Stated by London Ambulance Service NHS TrustStated planned
Action
Deliver the mandatory Core Skills refresher case-study training on ectopic pregnancy, hypovolaemia and fluctuating capacity to remaining operational staff.
Stated by London Ambulance Service NHS TrustStatus at response
Action
Issue a clinical bulletin reminding staff about alternative methods and resources for moving patients from scenes.
Stated by London Ambulance Service NHS TrustStated planned
Action
Review the feasibility and suitability of providing call handlers with real-time patient waiting-time information.
Stated by London Ambulance Service NHS TrustStated in progress
Action
Review the possibility of introducing a pre-hospital early warning score system in London.
Stated by London Ambulance Service NHS TrustStated in progress
Action
Develop a non-emergency patient transport service for patients who do not need immediate clinical treatment.
Stated by London Ambulance Service NHS TrustStated in progress
Action
Apply for student paramedics to be included in the NHS Bursary Scheme.
Stated by College of ParamedicsStated completed
Action
Write to ambulance services and higher education institutions offering assistance with paramedic recruitment activities.
Stated by College of ParamedicsStated planned
Action
Fund the Paramedic Evidence-based Education Project, supporting subsequent national review of its recommendations.
Stated by College of ParamedicsStated completed
Action
Raise the Consultant Gynaecologist’s pregnancy-triage recommendation with JRCALC and request its inclusion in the scheduled workstream agenda.
Stated by College of ParamedicsStated planned
Action
Continue promoting paramedic careers through the College website.
Stated by College of ParamedicsStated in progress
Action
Participate in national working groups or committees developing and establishing an early warning system compatible with receiving health facilities.
Stated by College of ParamedicsStated planned
Action
Raise a national pre-hospital early warning system with JRCALC and request its inclusion in the scheduled workstream agenda.
Stated by College of ParamedicsStated planned
Action
Publish a clinical case study and expert commentary on potential ruptured ectopic pregnancy in the August 2015 newsletter.
Stated by College of ParamedicsStated planned
Action
Publish revised Paramedic Curriculum Guidance, post-registration career framework and Scope of Practice Policy after addressing independent and HEE comments.
Stated by College of ParamedicsStated planned
Action
Write to ambulance services and higher education institutions about the revised curriculum guidance and offer course-development assistance through the endorsement process.
Stated by College of ParamedicsStated planned
Action
Ask JRCALC to explore incorporating formalised triage tools into the next clinical practice guideline iteration.
Stated by College of ParamedicsStated planned

Respondent positions 6

Position
The steps taken are considered sufficient to address the risk of future deaths from increasing ambulance response times.
Stated by NHS EnglandNo action considered necessary

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 9

1
Oversee implementation of all external clinical review recommendations through a delivery plan and quarterly NHS England LAS Oversight Group reviews.
Stated by NHS EnglandStated in progress
2
Commission and complete an external multi-professional review of LAS clinical risk management systems and related operational decision-making.
Stated by NHS EnglandStated completed
3
Establish specialist clinical teams in the clinical hub to support GP and primary-care referrals.
Stated by London Ambulance Service NHS TrustStated planned
4
Maintain increased Clinical Hub staffing and refined processes, skill mix and standard operating procedures for held and vulnerable calls.
Stated by London Ambulance Service NHS TrustStated completed
5
Replace the demand management plan with a scored surge management plan governing progression and decision-making.
Stated by London Ambulance Service NHS TrustStated completed
6
Work with the Metropolitan Police to improve triage of calls requesting an ambulance.
Stated by London Ambulance Service NHS TrustStated planned
7
Seek assurance that the statutory duty of candour is being complied with for notifiable safety incidents.
Stated by London Ambulance Service NHS TrustStated planned
8
Establish an expert paramedic group to contribute to clinical-practice guidance across sectors.
Stated by College of ParamedicsStated completed
9
Survey higher education providers about paramedic science education and provide the results to the Centre for Workforce Intelligence.
Stated by College of ParamedicsStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised15

Variation in paramedic training

Failure to implement or consider automated call recategorisation

Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues

Failure to provide call-handlers with feedback on current time-frames

Failure to address increasing ambulance response times

Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain

Insufficient availability of trained paramedics due to vacant positions

Shortfalls in the ability to undertake internal investigations

Failure of pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain

Insufficient crew knowledge of alternative patient extraction techniques

Failure to progress a pre-hospital validated early warning score system

Failure to implement or consider clinical re-triaging

Failure to address increasing ambulance response times

Lack of steps to take forward a pre-hospital validated early warning score system

Unaddressed ambulance service staffing vacancies

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.27

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

Actions described in response 27

Respondent positions 6