PFD report

Lisa Margaret DAY · Prevention of Future Deaths report

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Issued 23 Feb 2016•Inner North London

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

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 raised2

  1. Failure to explain the potentially grave consequences of vomiting illness in a person with diabetes to the caller
  2. Failure to discuss alternative hospital conveyance options with the person arranging care
    Part of recurring concern: Unreliable emergency access to hospital care
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

    Refer development of type 1 diabetes-specific vomiting information scripts to the NHS Pathways team for consideration.

    Stated by London Central & West Unscheduled Care Collaborative LimitedStated completedThe respondent said that this action was complete when they made their response on 23 February 2016.
  2. Action

    Implement the agreed London-wide protocol requiring clinicians to explain ambulance delays and self-transfer risks, involve callers, provide updates, and reiterate worsening instructions.

    Stated by London Central & West Unscheduled Care Collaborative LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 February 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The National NHS Pathways team was responsible for considering additional condition-specific scripting about vomiting in type 1 diabetes.

    Stated by London Central & West Unscheduled Care Collaborative LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 explain the potentially grave consequences of vomiting illness in a person with diabetes to the caller

Wider context from the report

“1. When Ms Day’s friend rang the 111 service on her behalf, the possibility of conveying her to hospital by means other than an ambulance was discussed with her and she declined. However, it was not discussed with her friend who made the call. He would have been much better placed to organise this and, if he had, it would probably have resulted in life saving hospital treatment. The potentially very grave consequences of a vomiting illness in a person with diabetes were not explained to him. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 discuss alternative hospital conveyance options with the person arranging care

Wider context from the report

“1. When Ms Day’s friend rang the 111 service on her behalf, the possibility of conveying her to hospital by means other than an ambulance was discussed with her and she declined. However, it was not discussed with her friend who made the call. He would have been much better placed to organise this and, if he had, it would probably have resulted in life saving hospital treatment. The potentially very grave consequences of a vomiting illness in a person with diabetes were not explained to him. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access to hospital care.

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

Refer development of type 1 diabetes-specific vomiting information scripts to the NHS Pathways team for consideration.

Verbatim wording from the response

“b) Vomiting in a person with diabetes”

Source location

Lisa-Day-Response
Page 3 · response
Published 23 February 2016

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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

Implement the agreed London-wide protocol requiring clinicians to explain ambulance delays and self-transfer risks, involve callers, provide updates, and reiterate worsening instructions.

Verbatim wording from the response

“It is acknowledged that this alternative means of conveyance if undertaken in Ms Day’s case may have resulted in life saving hospital treatment and as a result the group representing all London 111 providers have agreed the following amendment to the memorandum of understanding in place between the providers and the London Ambulance Service:”

Source location

Lisa-Day-Response
Page 3 · response
Published 23 February 2016

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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 NHS Pathways team was responsible for considering additional condition-specific scripting about vomiting in type 1 diabetes.

Verbatim wording from the response

“The 111 clinician did not offer specific information to Ms Day’s friend who was involved in the call process in relation to the significance of her symptoms of vomiting in type 1 diabetes. The clinician did give the recommended “worsening instructions”, which must accompany any 111 call for the process to be deemed compliant.”

Source location

Lisa-Day-Response
Page 3 · response
Published 23 February 2016

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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

Individual 111 providers cannot change system-wide practice, policy or training without approval from the appropriate authority.

Verbatim wording from the response

“LCW UCC is a licensed provider of 111 services and as such is required to comply with the NHS Pathways end user license. Any system-wide changes to 111 practice or systems including changes to standard practice, policy or training are therefore not within individual providers remit to change without the approval of the appropriate authority.”

Source location

Lisa-Day-Response
Page 2 · response
Published 23 February 2016

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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

Responsibility for the concern about explaining risks and discussing non-ambulance conveyance rests with the London Central and West Unscheduled Care Collaborative and Dr Ladbrooke.

Verbatim wording from the response

“I understand that the first concern is a matter for the London Central and West Unscheduled Care Collaborative and that Dr Ladbrooke will be responding.”

Source location

Lisa-Day-Response2
Page 1 · response
Published 23 February 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.2

  1. 1

    Implement an electronic NHS 111 clinician-alerting process to notify LAS Emergency Operations Control about clinically concerning calls.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2016.
  2. 2

    Share the Prevention of Future Deaths response with the National Ambulance Service Medical Directors’ Group and London NHS 111 service providers.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 February 2016.

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

  1. 1

    The ambulance disposition was appropriate under NHS Pathways assessment processes, so no change to that clinical decision was indicated.

    Stated by London Central & West Unscheduled Care Collaborative LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 an electronic NHS 111 clinician-alerting process to notify LAS Emergency Operations Control about clinically concerning calls.

Verbatim wording from the response

“With regard to the second concern, I am pleased to confirm that the London Ambulance Service NHS Trust (LAS) have agreed a process with NHS 111 whereby clinicians from NHS 111 can alert the LAS Emergency Operations Control about the calls made to NHS 111 where there is a clinical concern. The electronic flagging system was introduced on 14 March 2016 following consultation with NHS 111. The “LAS Department of Education and Development EOC Training Bulletin”, TB 02/16, dated 9 March 2016, and “111 Clinician alerting process for patients where there is a clinical concern on a green ambulance referral” v2.0 flowchart give examples of the patients whose presenting conditions are to be brought to the attention of the LAS.”

Source location

Lisa-Day-Response2
Page 1 · response
Published 23 February 2016

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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

Share the Prevention of Future Deaths response with the National Ambulance Service Medical Directors’ Group and London NHS 111 service providers.

Verbatim wording from the response

“As with other Regulation 28 Prevention of Future Deaths Reports this letter will be shared with the National Ambulance Service Medical Directors’ Group (NASMeD) who advise the Ambulance Association of Ambulance Chief Executives, and will also be shared with London NHS 111 service providers.”

Source location

Lisa-Day-Response2
Page 2 · response
Published 23 February 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 disposition was appropriate under NHS Pathways assessment processes, so no change to that clinical decision was indicated.

Verbatim wording from the response

“Since September 2014, if an ambulance disposition is returned on the 111 system, other than a red one or two category requiring an 8 minute emergency response, NHS England has required that all 111 service providers undertake an enhanced clinical assessment by a NHS pathways trained clinician. This is usually either an experienced Paramedic or registered nurse who determines whether an ambulance is required or whether there is a safe alternative that can be recommended.”

Source location

Lisa-Day-Response
Page 2 · response
Published 23 February 2016

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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