PFD report

Kevan FUNNELL · Prevention of Future Deaths report

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Issued 27 Feb 2018•Brighton and Hove

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised5

  1. Insufficient call-taker training and confidence to involve clinicians in difficult calls
    Part of recurring concern: Failure to provide timely clinical review during ambulance call handling
  2. Failure to provide an estimated arrival time and proactive safety follow-up for waiting callers
    Part of recurring concern: Unreliable communication of ambulance dispatch status and expectations
  3. Unavailability of responders for the designated response timeframe
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
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.4

  1. Action

    Improve demand forecasting so available ambulance and crew hours more closely match service demand.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
  2. Action

    Implement the NHS Pathways update strengthening guidance for assessing consciousness levels in conscious patients.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
  3. Action

    Work with commissioners on a jointly commissioned demand and capacity review to align resource requirements with service demand.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024.

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 call-taker training and confidence to involve clinicians in difficult calls

Wider context from the report

“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical review during ambulance 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

Failure to provide an estimated arrival time and proactive safety follow-up for waiting callers

Wider context from the report

“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

Is this part of a recurring concern?

Yes — Unreliable communication of ambulance dispatch status and expectations.

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

Unavailability of responders for the designated response timeframe

Wider context from the report

“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Insufficient ambulance service capacity for emergency calls.

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 flag clinically significant updates for call upgrading

Wider context from the report

“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached.

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 assign and maintain ownership of ambulance calls

Wider context from the report

“At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance dispatch and resource-allocation controls.

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

Improve demand forecasting so available ambulance and crew hours more closely match service demand.

Verbatim wording from the response

“In addition, the demand for our services on the night in question was greater than had been forecast. Since then, there has been much improvement in how we forecast and during 2018 the ambulance and crew hours we have available much more closely match the level of demand.”

Source location

Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024

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 the NHS Pathways update strengthening guidance for assessing consciousness levels in conscious patients.

Verbatim wording from the response

“On 22 November 2017, we implemented a significant update to NHS Pathways. The new version includes amendments to the supporting information for conscious patients, in order to try and make it more robust and easier for call takers in situations like this one, to identify consciousness levels. If this updated version had been in use in October 2017 then Mr Funnell would have been classified as unconscious. The disposition would therefore have most likely been a Red 2 response with a target attendance time of 8 minutes. This demonstrates the evolving nature of the Pathways system.”

Source location

Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024

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 commissioners on a jointly commissioned demand and capacity review to align resource requirements with service demand.

Verbatim wording from the response

“To summarise, it is clear that there was an error with the original classification of Mr Funnell and then a failure to upgrade his call. For this, I am sorry. Although this was human error, the recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring. We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”

Source location

Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024

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

Remind all call takers when to upgrade calls and seek senior guidance about NHS Pathways dispositions.

Verbatim wording from the response

“For Mr Funnell, the call taker did not seek to upgrade the call. This was human error. The manager of the Emergency Operations Centre (EOC) has used the learning from this case to remind all call takers about the circumstances to consider when upgrading a call and the need to seek senior guidance if there is any doubt about the disposition reached through NHS Pathways.”

Source location

Response from South East Coast Ambulance Service
Page 2 · response
Published 23 February 2024

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

  1. 1

    Existing provisions allow call takers to upgrade calls involving unsafe public places or weather and seek advice about the disposition.

    Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Existing provisions allow call takers to upgrade calls involving unsafe public places or weather and seek advice about the disposition.

Verbatim wording from the response

“I can confirm that there are adequate provisions in place, which provide for call takers to upgrade a call where the patient is in an unsafe public place (including when this relates to weather conditions) and to seek advice if they are concerned about the disposition reached.”

Source location

Response from South East Coast Ambulance Service
Page 1 · response
Published 23 February 2024

Open published response
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Data last updated 7 September 2026