PFD report

Peggy COPEMAN · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 28 May 2021•Norfolk

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised5

  1. Failure to ensure transport staffing complies with the CPR training requirement
    Part of recurring concern: Failure to ensure mandatory safety training is completed before safety-critical work
  2. Insufficient CPR-trained staffing for patient transport
    Part of recurring concern: Insufficient qualified healthcare staffing capacityPart of recurring concern: Unsafe assignment of staff without the required qualifications or competence to care work
  3. Failure of internal investigation to identify concerns about emergency response and CPR safety
    Part of recurring concern: Inadequate safety incident investigations
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.5

  1. Action

    Establish an authorised internal training capacity by qualifying a staff member to train others within the company.

    Stated by Premier Rescue Ambulance Service LtdStated completedThe respondent said that this action was complete when they made their response on 2 June 2021.
  2. Action

    Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.

    Stated by Premier Rescue Ambulance Service LtdStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2021.
  3. Action

    Implement a transport policy refusing patients who are not awake and responsive, requiring medical fitness confirmation and medication details for transfer risk assessment.

    Stated by Premier Rescue Ambulance Service LtdStated completedThe respondent said that this action was complete when they made their response on 2 June 2021.

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 ensure transport staffing complies with the CPR training requirement

Wider context from the report

“1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

Is this part of a recurring concern?

Yes — Failure to ensure mandatory safety training is completed before safety-critical work.

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 CPR-trained staffing for patient transport

Wider context from the report

“1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity; Unsafe assignment of staff without the required qualifications or competence to care work.

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

Failure of internal investigation to identify concerns about emergency response and CPR safety

Wider context from the report

“1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Failure to enable effective CPR in the patient transport vehicle

Wider context from the report

“1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

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

Failure to promptly recognise and respond to respiratory distress or cardiac arrest during patient transport

Wider context from the report

“1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unreliable resuscitation preparedness and response during cardiac arrest.

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

Establish an authorised internal training capacity by qualifying a staff member to train others within the company.

Verbatim wording from the response

“1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

Source location

2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Page 1 · response
Published 2 June 2021

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 basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.

Verbatim wording from the response

“1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

Source location

2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Page 1 · response
Published 2 June 2021

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 a transport policy refusing patients who are not awake and responsive, requiring medical fitness confirmation and medication details for transfer risk assessment.

Verbatim wording from the response

“7. Premier Rescue Ambulance Service Ltd., have now implemented a Policy that they are no longer prepared to accept for transport, patients who are not awake and responsive at the commencement of the journey. This is so they can actually assess any changes in their behaviour on the journey. They will also require a signed document from a qualified Medical Practitioner confirming a patient’s fitness to travel and also require a detailed list of medications patients are receiving so as to enable them to carry out a risk assessment as to whether it is appropriate for those patients to be transferred by Premier Rescue Ambulance Service Ltd. The detailed list of medications will be reviewed by ████████ and ████████. Those Policies have been implemented immediately.”

Source location

2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Page 3 · response
Published 2 June 2021

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

Investigate the possibility of appointing a qualified independent assessor for future internal investigations.

Verbatim wording from the response

“5. The Company regret their initial investigation did not highlight ████████ ████████ or ████████ as not having CPR training. They have now revised their internal investigation procedure and they are now investigating the possibility of a qualified independent assessor carrying out such a role in the future should the need arise. In the meantime, any internal investigation pending such an appointment will be carried out by”

Source location

2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Page 2 · response
Published 2 June 2021

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

Revise and immediately implement the internal investigation procedure, assigning interim investigations to a fully trained State Registered Nurse.

Verbatim wording from the response

“4. Premier Rescue Ambulance Service Ltd., merely observe that the request to transfer Peggy Copeman was received late in the afternoon of the 15th December with a request to transfer her on the morning of the 16th December. Accepting instructions such as this in such a short timeframe has been identified by the Company as a weakness in procedures which led to two untrained staff accompanying one trained member of staff.”

Source location

2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
Page 2 · response
Published 2 June 2021

Open published response
Back to top

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