PFD report

Christopher Philip Fields · Prevention of Future Deaths report

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Issued 18 May 2016•Manchester South

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
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
6

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 raised4

  1. Failure to safeguard an injured or intoxicated vulnerable person before police departure
    Part of recurring concern: Failure to recognise vulnerability in safeguarding decisionsPart of recurring concern: Unreliable management and control of emergency incident scenes
  2. Failure to protect a witness from an assailant during police information gathering
  3. Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
    Part of recurring concern: Unreliable ambulance call triage and re-triagePart of recurring concern: Unreliable ambulance-service computer systems for safety-critical informationPart of recurring concern: Unsafe emergency call handling
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

    Explore ways to minimise lengthy ambulance waits during high-demand periods.

    Stated by North West Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2016.
  2. Action

    Secure funding for 400 additional frontline staff and 60 new vehicles.

    Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2016.
  3. Action

    Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.

    Stated by North West Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 safeguard an injured or intoxicated vulnerable person before police departure

Wider context from the report

“1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death. Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE) ”

Is this part of a recurring concern?

Yes — Failure to recognise vulnerability in safeguarding decisions; Unreliable management and control of emergency incident scenes.

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 protect a witness from an assailant during police information gathering

Wider context from the report

“1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death. Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE) ”

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

Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients

Wider context from the report

“3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response, suggests that the algorithms used for coding are not accurate and not fit for purpose. In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied. (NWAS, SECRETARY OF STATE and NHS ENGLAND) ”

Is this part of a recurring concern?

Yes — Unreliable ambulance call triage and re-triage; Unreliable ambulance-service computer systems for safety-critical information; Unsafe emergency call handling.

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

Delays in ambulance response to coded emergency calls

Wider context from the report

“2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes. Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS) ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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

Explore ways to minimise lengthy ambulance waits during high-demand periods.

Verbatim wording from the response

“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.”

Source location

2016-0194-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 18 May 2016

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

Secure funding for 400 additional frontline staff and 60 new vehicles.

Verbatim wording from the response

“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which I hope will assist in alleviating some of these pressures.”

Source location

2016-0194-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 18 May 2016

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

Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.

Verbatim wording from the response

“NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

Source location

2016-0194-Response-by-NHS-England
Page 1 · response
Published 18 May 2016

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

Trial a new ambulance coding system.

Verbatim wording from the response

“NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

Source location

2016-0194-Response-by-NHS-England
Page 1 · response
Published 18 May 2016

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

Complete wider vulnerability work incorporating lessons learned from this case.

Verbatim wording from the response

“It is proposed that we will be able to report back to the Coroners. In October 2016 in terms of the wider work we are completing around vulnerability, including the lessons learnt from this case.”

Source location

2016-0194-Response-by-Greater-Manchester-Police
Page 3 · response
Published 18 May 2016

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 AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.

Verbatim wording from the response

“In regards to AMPDS system, I confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s chest had been ‘concealed in’ this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response. I note that the attending police officers evidence supported that the patient was breathing, conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patient’s condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment). Furthermore this assertion was reinforced by ████████ Pathologist report which supported that the critical injury was sustained during the second assault.”

Source location

2016-0194-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 18 May 2016

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

Green 2 requires attendance as soon as practicable, not necessarily within 20 minutes; the delay reflected exceptional activity and hospital turnaround pressures.

Verbatim wording from the response

“Taking each point in turn, I confirm that the vehicle response time for the incident in question, was inextricably linked to the activity pressures, NWAS faced during this extremely challenging winter period. Despite winter weather contingency planning, activity within the Greater Manchester area saw an unexpected 22% increase, which was directly compounded by significant hospital turnaround pressures faced at Stepping Hill, North Manchester and Oldham.”

Source location

2016-0194-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 18 May 2016

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

Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.

Verbatim wording from the response

“However, please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concerns about the design of the product you may wish to contact them direct at the following address:”

Source location

2016-0194-Response-by-Department-of-Health
Page 2 · response
Published 18 May 2016

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 ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.

Verbatim wording from the response

“I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.”

Source location

2016-0194-Response-by-Department-of-Health
Page 2 · response
Published 18 May 2016

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 ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.

Verbatim wording from the response

“I note the response from North West Ambulance Service (NWAS), letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time. It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist’s report.”

Source location

2016-0194-Response-by-NHS-England
Page 1 · response
Published 18 May 2016

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 Decision Making Model is considered sufficient for officers to assess risks and decide whether to remain at a scene.

Verbatim wording from the response

“No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

Source location

2016-0194-Response-by-Greater-Manchester-Police
Page 1 · response
Published 18 May 2016

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

Specific waiting times cannot be formalised because circumstances vary and fixed timescales would be impractical.

Verbatim wording from the response

“No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

Source location

2016-0194-Response-by-Greater-Manchester-Police
Page 1 · response
Published 18 May 2016

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.1

  1. 1

    Apply management action addressing deficiencies in officers’ pocket notebook documentation and inaccurate recording.

    Stated by Ian Hopkins QPM., MBAStated completedThe respondent said that this action was complete when they made their response on 18 May 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Officers could not lawfully arrest anyone because available information provided insufficient grounds to suspect criminal involvement.

    Stated by Ian Hopkins QPM., MBAUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Apply management action addressing deficiencies in officers’ pocket notebook documentation and inaccurate recording.

Verbatim wording from the response

“In relation to the learning that has arisen out of this case, ████████ was given management action for the lack of documentation within his pocket note book. Errors in recording inaccurate information was addressed in the witness evidence of ████████ Operational Communications Branch Business Lead at Inquest.”

Source location

2016-0194-Response-by-Greater-Manchester-Police
Page 3 · response
Published 18 May 2016

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

Officers could not lawfully arrest anyone because available information provided insufficient grounds to suspect criminal involvement.

Verbatim wording from the response

“Both officers gave clear, unambiguous evidence that they did not consider ████████ to have been the perpetrator, and in such circumstances there would be no grounds for an arrest. The Police and Criminal Evidence Act 1984, requires for a lawful arrest when there are reasonable grounds for suspecting a person’s involvement or attempted involvement in the commission of a criminal”

Source location

2016-0194-Response-by-Greater-Manchester-Police
Page 2 · response
Published 18 May 2016

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