Emergency dispatch algorithm flaws (medication)
Emergency dispatch algorithms failing to account for blood-thinning medication in head injury cases, delaying appropriate response.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
Roy Middleton
The coroner noted that the International Academies of Emergency Dispatch algorithm for emergency response does not consider whether a patient is on blood-thinning medication for head injuries, raising concerns that this could lead to future deaths.
Matched on
terms: algorithm, dispatch, emergency, medication
Inquiry recommendation
74match
MAI-104 - Review Advanced Medical Priority Dispatch System
The Department of Health and Social Care and the National Ambulance Resilience Unit should consider whether the Advanced Medical Priority Dispatch System is fit for purpose and, if it is, whether it can be improved. Particular consideration should be given to how the system prioritises emergency calls.
Matched on
terms: dispatch, emergency
PFD report
73match
James Sutton
The London Ambulance Service did not automatically link specific risk factors, including age, fall height, and anti-clotting medication, to trigger an 8-minute emergency response for Mr Sutton.
Matched on
terms: emergency, medication
PFD report
73match
Yusuf Abdismad
The coroner noted concerns about the emergency medical dispatcher's confusing questioning method to ascertain a patient's consciousness. The report suggests a more direct follow-up question, such as "Can you wake him?", would be more appropriate.
Matched on
terms: dispatch, emergency
PFD report
69match
Martin Sullivan
The MPDS script and algorithm did not adequately recognise a life-threatening asthma attack, failing to account for cumulative symptoms or proactively elicit details on ineffective breathing. NWAS consistently failed to meet Category 2 response targets.
Matched on
terms: algorithm
PFD report
69match
Colin Swain
The coroner raised concerns regarding the Medical Priority Dispatch System's algorithm for patients known to have consumed alcohol, specifically whether it includes guidance for clearing airways. Concerns were also noted about the practice of placing an unconscious, vomiting patient onto their back in the absence of clinical support.
Matched on
terms: algorithm, dispatch
PFD report
69match
Keith Hopwood
Ambulance service resource constraints caused delays and the dispatch of a private ambulance unequipped for cardiac patients. The call handling algorithm also lacked prompts to explore critical patient comments, and a disconnected call from a lone patient did not automatically escalate.
Matched on
terms: algorithm, dispatch
PFD report
69match
Margaret Huntley
The coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the awareness and use of Steroid Emergency Cards, and GPs not routinely using the option to place alerts on ambulance systems for specific patient conditions.
Matched on
terms: emergency, medication
PFD report
65match
Toni Skillington
The Medical Priority Dispatch System does not include methadone as an overdose drug choice or ask if a patient is alone. There were also concerns about a three-hour delay in paramedic response to an overdose call and a lack of appropriate follow-up after failed welfare checks.
Matched on
terms: dispatch
PFD report
65match
Marie Millward-Winter
The coroner noted concerns regarding ambulance technicians administering anticoagulation medication (Apixaban) to Mrs Millward Winter after a head injury. This administration worsened an internal bleed and contributed to her death.
Matched on
terms: medication
PFD report
65match
Kenneth Adams
The MPDS protocol for assessing scalp lacerations does not adequately account for persistent bleeding, the impact of antiplatelet or anticoagulant medication, or the increasing risk of hypovolaemic shock, resulting in inappropriately low ambulance priority.
Matched on
terms: medication
PFD report
61match
Sharon Butcher
The coroner noted a 10-minute delay in calling an ambulance after an emergency code, with the local protocol not followed. Similar issues with medical emergency responses, including incorrect codes and control room delays, have occurred at other prisons.
Matched on
terms: emergency
PFD report
61match
Hayden Norton
The coroner noted a lack of blood pressure monitoring and no record of informing the patient about aortic aneurysm screening at HMP Dartmoor. There was also a delay in calling an emergency ambulance due to the absence of an emergency code protocol.
Matched on
terms: emergency
PFD report
61match
Christopher Fields
The coroner identified issues with police decision-making in leaving a vulnerable person before an ambulance arrived. Concerns also included a significant ambulance response delay and the inadequacy of call coding algorithms to assign a Red response for critical injuries.
Matched on
terms: algorithm
PFD report
61match
Hannah Royle
The coroner identified issues with 111 service call handlers not correctly following algorithms or recognising complex cases involving disabilities, alongside a lack of robust systems for disabled callers. Concerns also included inadequate clinical advisor expertise and the public being potentially misled about the 111 service's role.
Matched on
terms: algorithm
PFD report
61match
Lucas Pollard
The coroner raised concerns that a Critical Care Team was not immediately dispatched and a rapid response vehicle was not deployed due to the application of an End Of Shift Policy, despite clear evidence of patient deterioration during the 999 call.
Matched on
terms: dispatch
PFD report
61match
Miles Robinson
The Medical Priority Dispatch System (MPDS) used by the London Ambulance Service lacks specific determinants for heart attack under its Chest Pain protocol, meaning these calls do not receive a Category 1 response. This rigidity may increase the risk of death from cardiac arrest due to delayed ambulance arrival.
Matched on
terms: dispatch
HSSIB recommendation
61match
Potential under-recognised risk of harm from the use of propranolol
The Ambulance Trust has recognised the limitation of the local variation to its call handling policy and raised a case with the AMPDS dispatch academy to ask that propranolol be added to the list of medicines within AMPDS that can be coded as a Category 2 response. 5.2 Analysis and findings from the wider investigation Triage systems
Matched on
terms: dispatch
PFD report
57match
Barbara Patterson
The Pathways system fails to prompt CPR advice for agonal breathing, a known fault Pathways has not amended. There were also delays in ambulance dispatch and arrival, partly due to paramedic shortages and hospital handover delays.
Matched on
terms: dispatch
PFD report
57match
Barry Hodges
The coroner noted that ambulance dispatch protocols and resource review were not followed, with a lack of a safety net system and insufficient staff knowledge of protocols. Time limits were breached without escalation or resource allocation.
Matched on
terms: dispatch
PFD report
57match
Susan Longden
The NHS Pathways algorithm lacks a question regarding recent surgical procedures for patients reporting severe abdominal pain. There is also insufficient emphasis on speaking directly with the patient when a non-patient makes the NHS 111 call.
Matched on
terms: algorithm
PFD report
57match
Christopher Williams
The coroner noted delays in ambulance arrival and treatment at the hospital due to communication failures regarding a pre-arranged bed. Concerns were also raised about the call handler's failure to escalate the patient's worsening condition and the absence of a neurological algorithm in the triage system.
Matched on
terms: algorithm
PFD report
57match
Allan Davies
The coroner noted that ambulances dispatched to Mr Davies' Category 3 overdose call were repeatedly diverted to higher priority patients during a period of high demand, leading to a delay in attendance.
Matched on
terms: dispatch
PFD report
57match
Esma Guzel
The coroner identified limitations in the 111 algorithm regarding the assessment of parental concern, prior GP review, and timing of advice requests for paediatric referrals. Additionally, the report notes a need for professional bodies to disseminate information on rare conditions and endorse 111 as a definitive safety net.
Matched on
terms: algorithm
PFD report
57match
Rashdah Bhatti
The Medical Priority Dispatch System's advice for varicose vein bleeds was not consistently provided due to human error, and there was no evidence of the effectiveness of staff reminders to prevent this.
Matched on
terms: dispatch
PFD report
57match
Fern Foster
The ambulance triage process for suspected ingestion incidents does not allow sufficient time for critical interventions. Additionally, there is no regional or national protocol for ambulance services to carry and administer specific antidote medication on-scene.
Matched on
terms: medication
PFD report
57match
Amanda Gainford
Concerns were raised that many clinicians are unaware they can challenge 999 call categorisation by NWAS and seek a clinical review, which could impact ambulance dispatch for critical patients.
Matched on
terms: dispatch
PFD report
57match
Lee Armstrong
The NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
Matched on
terms: emergency
PFD report
57match
Jeffrey Tyler
The Medical Priority Dispatch System (MPDS) did not allow for an upgrade in ambulance urgency despite evident clinical deterioration and the patient being alone, leading to a prolonged waiting time.
Matched on
terms: dispatch
PFD report
57match
Oscar Keenan
The coroner raises concerns about the current algorithm for assessing ill newborns/infants, noting its inadequacies in identifying respiratory problems and that reliance on it can delay early clinical assessment.
Matched on
terms: algorithm
LGO / SPSO decision
54match
202000766 - Scottish Ambulance Service
C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in...
Matched on
terms: dispatch, emergency
PFD report
53match
Winston Llewellyn Johns
The coroner noted that crucial low blood sugar information was not considered in the advice provided by the ambulance operator. Additionally, the ambulance service's computer program did not account for critical clinical information, leading to incorrect CPR advice.
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PFD report
53match
Elizabeth Lester
The ambulance service's call script for breathing difficulties does not include a question about chest pain, which can lead to inappropriate call prioritisation. This omission can delay the allocation of an urgent response.
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PFD report
53match
Joel Colk
The NHS Pathways system for overdose calls does not adequately differentiate between types or severity of ingestion, which impacts response urgency. Additionally, ambulances lack a specific antidote, Methylene Blue, delaying crucial treatment often beyond the point of effectiveness.
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classifier match
PFD report
49match
Glyn Ackerley
The coroner noted that the national NHS Pathways process does not differentiate between high-risk and low-risk overdoses, which risks delaying prompt treatment for individuals who have taken a potentially fatal overdose.
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classifier match
PFD report
49match
Aran Bradbury
The ambulance service's triage system prioritised mental illness over substance ingestion for a patient with both, leading to a lower category response. This system logic prevents a higher priority being assigned when both conditions are present.
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PFD report
49match
John England
The ambulance service's MDPS system may not be sufficiently nuanced to distinguish between different types of abdominal surgical emergencies, potentially leading to an inappropriate disposition and delayed conveyance to hospital.
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classifier match
HSSIB recommendation
48match
Delayed recognition of acute aortic dissection
In release 18, NHS Digital has amended the content of the NHS Pathways algorithm used for telephone triage of patients, to help improve recognition of chest pain likely to be associated with acute aortic dissection.
Matched on
terms: algorithm
Scottish FAI
48match
Alison Aikman Duguid
Recommendations When officers are advised of the need for medication, they should get it. The system of classification of calls should be more sophisticated and there should be a more sophisticated grading system. Grampian Police themselves are contemplating having five gradings rather than four and that would result from a splitting of Grade 2. The calls in the...
Matched on
terms: medication
PHSO casework decision
48match
P-003096 - NHS England
The 111 call handler failed to recognise the urgency of her husband's condition, leading to delayed hospitalisation for a perforated bowel and sepsis, and subsequent death. She also challenged the flawed NHS Pathways triage system.
Matched on
terms: flaw
LGO / SPSO decision
46match
201705035 - Scottish Ambulance Service
Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably. Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting for an operation. Mr C said that Mrs...
Matched on
terms: dispatch, emergency
LGO / SPSO decision
46match
201707301 - Scottish Ambulance Service
Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that...
Matched on
terms: dispatch, emergency
LGO / SPSO decision
46match
201708212 - Scottish Ambulance Service
Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance. We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours,...
Matched on
terms: dispatch, emergency
PFD report
45match
Refat Hussain
The coroner noted that out-of-hours GPs working for Harmoni lacked access to patients' GP medical records, which reduced their ability to make accurate diagnoses.
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classifier match
PFD report
45match
Clare Bain
The coroner noted concerns that paramedics may not be fully aware that Methadone's respiratory depressive effects last longer than Naloxone's antagonism, which could lead to a lack of repeat treatment doses when opiates are still active.
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classifier match
PFD report
45match
Linda Lloyd
The coroner noted that hospital procedures were insufficiently robust and staffing levels did not provide enough resilience to minimise the risk of further deaths in similar circumstances.
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PFD report
45match
Monica Lewis-Hinds
The London Ambulance Service's call triage protocol does not require call handlers to explicitly ask about the "type of fit," only completing the section if the caller offers the information, which the coroner suggests may need amendment.
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PFD report
45match
Caragh Melling
The current NHS Pathways triage system used by the Ambulance Trust lacks a specific tool to recognise agonal or inadequate breathing, which was present in a previous system. Concerns about this omission have been raised nationally since 2014, but no action appears to have been taken.
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PFD report
45match
Terrence Smith
The current NHS Pathways system does not enable ambulance call handlers to recognise Excited Delirium/Acute Behavioural Disturbance, pending an update. Concerns were also raised regarding potentially confusing interim guidance for call handlers and the content of clinical staff training on this condition.
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PFD report
45match
Alexander Davidson
The NHS 111 service used medical terminology unclear to young patients and rigid scripts. Concerns were also raised about delays in GP uploading of triage notes and the lack of routine lipase/amylase testing for young people with abdominal symptoms.
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