PFD report

Edna May Wiggett · Prevention of Future Deaths report

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Issued 18 Mar 2026•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised1

  1. Failure to re-triage and re-classify cases when subsequent relevant information is received
    Part of recurring concern: Unreliable ambulance call triage and re-triage
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.2

  1. Action

    Publish a Patient Safety and Experience Newsletter article reminding staff to re-triage calls when presentations change.

    Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  2. Action

    Discuss re-triage learning and potential themes at the Learning Group.

    Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Re-triage at the second call was unlikely to produce a higher categorisation because pain is excluded from AMPDS triage questions.

    Stated by East of England 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 re-triage and re-classify cases when subsequent relevant information is received

Wider context from the report

“(1) the failure to re-triage Mrs. Wiggett’s case and consider a re-classification following receipt of a second call providing relevant information (an increase in pain) leading to delays in the dispatch of an ambulance. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance call triage and re-triage.

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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

Publish a Patient Safety and Experience Newsletter article reminding staff to re-triage calls when presentations change.

Verbatim wording from the response

“A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.”

Source location

Response from East of England Ambulance NHS Trust
Page 2 · response
Published 26 March 2026

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

Discuss re-triage learning and potential themes at the Learning Group.

Verbatim wording from the response

“A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.”

Source location

Response from East of England Ambulance NHS Trust
Page 2 · response
Published 26 March 2026

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

Re-triage at the second call was unlikely to produce a higher categorisation because pain is excluded from AMPDS triage questions.

Verbatim wording from the response

“A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.”

Source location

Response from East of England Ambulance NHS Trust
Page 2 · response
Published 26 March 2026

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

    Communicate the investigation-report learning internally for consideration.

    Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.

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

Communicate the investigation-report learning internally for consideration.

Verbatim wording from the response

“A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.”

Source location

Response from East of England Ambulance NHS Trust
Page 2 · response
Published 26 March 2026

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