Emergency dispatch algorithm flaws (medication)
Emergency dispatch algorithms failing to account for blood-thinning medication in head injury cases, delaying appropriate response.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
55 PFD reports
4 HSSIB recs
2 Scottish FAIs
11 PHSO decisions
15 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(55)— showing 50 strongest matches
Winston Llewellyn Johns
Concerns: 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.
Overdue
Refat Hussain
Concerns: 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.
Response (Care UK): • Care UK implemented a Special Patient Notes (SPN) system to receive information from GPs about patients with long-term conditions, vulnerabilities, or who are very poorly. • Care UK is … (AI summary)
Responded
James Sutton
Concerns: 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.
Overdue
Toni Skillington
Concerns: 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.
Overdue
Clare Bain
Concerns: 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.
Response (South Western Ambulance Service NHS Foundation Trust): • The Trust stated it would issue further guidance for clinicians by October 2014 to raise awareness of methadone overdose treatment, including the difference in half-life between methadone and naloxone … (AI summary)
Responded
Linda Lloyd
Concerns: 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.
Overdue
Sharon Butcher
Concerns: 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.
Response (HM Prison and Probation Service): • HMP Frankland revised local contingency plans and re-issued instructions to staff regarding calling an ambulance. • An additional learning bulletin was issued nationally by ERDG in April 2015. • … (AI summary)
Overdue
Hayden Norton
Concerns: 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.
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust undertook a baseline review of compliance with national guidelines for blood pressure monitoring and found full compliance. • The Trust now provides an Aortic Aneurysm Screening (AAA) … (AI summary)
Overdue
Barbara Patterson
Concerns: 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.
Response (Department of Health): • The NHS Pathways system is subject to ongoing review and updates, with amendments made to supporting information on breathing assessment. • The North East Ambulance Service has reduced its … (AI summary)
Response (CQC): • The CQC was monitoring an action plan submitted by North East Ambulance Service (NEAS) following previous inspections in February 2014 where non-compliance was identified. • The CQC intends to … (AI summary)
Response (North East Ambulance Service NHS Trust): • The Trust had conducted an investigation into the issues raised. • The Trust had provided management evidence regarding the issues. (AI summary)
Responded
Yusuf Abdismad
Concerns: 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.
Overdue
Elizabeth Lester
Concerns: 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.
Response (Department of Health): • The Department of Health noted that the Advanced Medical Priority Dispatch System (AMPDS) is an international call handling system developed by the Priority Dispatch Corporation. • The Department of … (AI summary)
Responded
Monica Lewis-Hinds
Concerns: 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.
Overdue
Caragh Melling
Concerns: 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.
Overdue
Christopher Fields
Concerns: 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.
Response (North West Ambulance Service NHS Trust): • The Trust has secured funding for 400 additional frontline staff and 60 new vehicles. • The Trust is exploring methods to minimise lengthy waits during periods of high demand. (AI summary)
Response (Department of Health): • The Department of Health stated that the algorithms used for coding emergency calls are not considered inaccurate or unfit for purpose. • It was noted that the initial emergency … (AI summary)
Response (Greater Manchester Police): • An officer received management action for issues with documentation in their pocket notebook. • Errors in recording inaccurate information were addressed through witness evidence at the inquest. • Greater … (AI summary)
Response (NHS England): • NHS England is leading a review of ambulance coding systems and trialling a new system. • The review will consider outcomes of previous 999 calls and concerns raised by … (AI summary)
Responded
Barry Hodges
Concerns: 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.
Response (South Yorkshire Ambulance Service): • A "Call Alert" system and a "minus minute" indicator were introduced on dispatch screens to highlight unallocated incidents and monitor resource allocation times. • Timeframes for resourcing amber category … (AI summary)
Responded
Susan Longden
Concerns: 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.
Response (NHS England): • NHS Pathways is reviewing its abdominal pain algorithms, including the severe pain section, to consider the inclusion of a question about recent surgical procedures. • This review is scheduled … (AI summary)
Responded
Marie Millward-Winter
Concerns: 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.
Response (North West Ambulance Service NHS Trust): • The Trust's Head of Legal Services interviewed the attending crew member to obtain an account of discussions with nursing home staff regarding medication administration. • An Advanced Paramedic reviewed … (AI summary)
Responded
Terrence Smith
Concerns: 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.
Overdue
Alexander Davidson
Concerns: 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.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated it would reconsider the scope of its pancreatitis guideline (NG104) when it is next reviewed. (AI summary)
Response (NHS England): • NHS Pathways confirmed call handlers receive communication skills training, including adapting questioning styles and avoiding jargon, supported by monthly call audits. • NHS Pathways reviewed the question regarding 'dark … (AI summary)
Overdue
Christopher Williams
Concerns: 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.
Response (East of England Ambulance Service NHS Trust): • The Trust has recruited 491 frontline staff and worked with system partners to address hospital handover delays. • It has reinforced escalation processes in initial training and one-to-one sessions … (AI summary)
Responded
Alf Rewin
Concerns: The coroner identified matters giving rise to concern during the inquest, noting a risk that future deaths could occur unless action is taken.
Response (NHS England): • Release 18 of NHS Pathways, deployed from October 2019, included a new disposition code (Dx0124) to facilitate early clinical review of higher-risk suicidal patients. • NHS England issued letters … (AI summary)
Responded
Allan Davies
Concerns: 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.
Response (NHS England): • NHS England and NHS Improvement wrote to all Ambulance Service Chief Executives and Medical Directors to highlight the issue and request robust clinical oversight in control rooms. • NHS … (AI summary)
Response (NHS England): • NHS Pathways introduced a new disposition code (Dx0124) in February 2019 to facilitate early identification of higher-risk suicidal patients for urgent clinical assessment. • Widespread deployment of the new … (AI summary)
Responded
Anna Hedman
Concerns: The coroner identified that training for part-time police call handlers was too short and rushed, especially for call coding, and did not adequately emphasize preservation of life. Post-training coaching and mentoring were also deemed insufficient.
Overdue
Ashley Walker
Concerns: The coroner identified a communication error that confused ingestion with spillage and noted that an effective antidote for toxicity was not available on the ambulance.
Response (West Midlands Ambulance Service): • Staff were instructed to remove the WISER App from work mobile devices, with its use restricted to trained Tactical Incident Commanders, National Inter-Agency Liaison Officers, and Hazardous Area Response … (AI summary)
Responded
Mitica Marin
Concerns: The coroner identified delayed defibrillation due to a paramedic not activating the automatic mode on a defibrillator that defaults to manual, a factor in similar incidents. The report suggests defaulting to automatic mode or requiring a mode choice on startup could prevent future delays.
Response (Resusciation Council UK): • Resuscitation Council UK stated its preference for manual defibrillation mode for advanced life support. • It expressed concern that recommending an automatic start-up mode could worsen overall outcomes. • … (AI summary)
Response (London Ambulance Service NHS Trust): • The London Ambulance Service (LAS) produced clinical update material mandating that defibrillators be initially placed in AED mode for all cardiac arrests. • Large yellow indicator stickers were placed … (AI summary)
Response (Association of Ambulance): • The Association of Ambulance Chief Executives (AACE) undertook an extensive review of the resuscitation sections of its clinical practice guidelines. • AACE issued revised guidance to UK ambulance services … (AI summary)
Response (Dept. Health and Social Care): • The London Ambulance Service provides training to staff and issued updated cardiac care guidance in October 2019, advising initial use of AED mode for the LIFEPAK 15. • The … (AI summary)
Response (Stryker Corporation Physio Control): • Stryker stated that the LP15 monitor/defibrillator is designed to be configured to power on in either automatic or manual defibrillation mode. • Stryker indicated it would not take any … (AI summary)
Responded
Faiza Ahmed
Concerns: The coroner's concerns are encompassed within the jury’s determination attached to the report.
Response (the Department of work and Pensions): • The Department for Work and Pensions (DWP) operates a Six Point Plan framework for staff to manage customer declarations of intention to attempt suicide or self-harm. • DWP staff … (AI summary)
Response (the London Ambulance Service): • The crew involved undertook reflective learning, and a clinical update was published in April 2015 reinforcing the assessment of capacity. • A new Operational Management Structure was implemented, introducing … (AI summary)
Response (the Metropolitan Police): • The Metropolitan Police implemented the Vulnerability Assessment Framework (VAF) and CARES approach, including training for frontline officers, to enhance the recognition and support of vulnerable individuals. • The Metropolitan … (AI summary)
Responded
Zoe Knight
Concerns: The coroner raised concerns that a Healthcare Safety Investigation Branch recommendation to add 'aortic pain' to the Manchester Triage System, intended to improve awareness and diagnosis of acute aortic dissection, has not been implemented.
Response (NICE 2020): • NICE guideline CG95 includes recommendations for healthcare professionals to consider aortic dissection. • A surveillance review of guideline CG95 was conducted in 2019, which concluded that no update was … (AI summary)
Responded
Jack Goodwin
Concerns: The ambulance service's call handling script did not adequately provide realistic ambulance arrival times or discuss alternative transport during busy periods. It also lacked emphasis on selecting an acute hospital for direct transfer and the importance of re-calling if the patient deteriorated.
Response (NHS England): • Ambulance services committed to amending case exit scripts to provide estimated waiting times for lower acuity calls. • Ambulance services enhanced case exit scripts during the Covid-19 pandemic to … (AI summary)
Responded
Martin Sullivan
Concerns: 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.
Response (Clinical Commissioning Group): • The Clinical Commissioning Group reported that NWAS implemented training for call takers, issued operational educational bulletins, and introduced an electronic 'pop up' to aid in identifying ineffective breathing. • … (AI summary)
Response (NHS England): • NHS England and NHS Improvement will hold a learning event with all ambulance services, involving triage system providers, to share best practice. • The event aims to ensure ambulance … (AI summary)
Responded
Mark Holden
Concerns: A DVT was not diagnosed due to lack of physical examination during a telephone GP consultation, and a high D-Dimer result did not trigger an electronic system alert. Also, existing NICE guidance lacked Covid-19 specific risk information for clots.
Overdue
Hannah Royle
Concerns: 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.
Response (South East Coast Ambulance Service): • A "Hot Topic" learning module on identifying and referring complex cases was issued to all 111 call handling staff. • The handling of complex calls has been added as … (AI summary)
Response (NHS England): • NHS Pathways developed and released additional learning content for all system users, focusing on learning disabilities and communication strategies. • This new learning material was included in updated core … (AI summary)
Overdue
Colin Swain
Concerns: 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.
Overdue
Keith Hopwood
Concerns: 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.
Response (Department of Health and Social Care): • NHS England allocated £150 million for ambulance service pressures and £20 million to upgrade the ambulance fleet. • The government committed to increasing NHS bed capacity by the equivalent … (AI summary)
Responded
Esma Guzel
Concerns: 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.
Response (Royal College of Paediatrics and Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) will engage in further discussions with NHS Pathways to understand changes made to 111 algorithms and consider future work to … (AI summary)
Response (Royal College General Practitioners): • The Royal College of General Practitioners (RCGP) detailed its curriculum for GPs in training, which extensively covers paediatrics, child health, paediatric emergencies, and gastrointestinal conditions. • The RCGP confirmed … (AI summary)
Response (NHS England): • The vomiting blood pathways were modified to improve the identification of 'critical illness'. • Additional questions on breathlessness and confusion were added to the critical illness triage assessment. • … (AI summary)
Responded
Roy Middleton
Concerns: 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.
Overdue
Kenneth Adams
Concerns: 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.
Responded
Rashdah Bhatti
Concerns: 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.
Response (Welsh Ambulance Service NHS Trust): • The Trust undertook a focused audit of calls related to protocol 21 (Haemorrhage/laceration) in October 2023. • The Trust will issue a reminder to all call handlers regarding the … (AI summary)
Responded
Glyn Ackerley
Concerns: 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.
Response (NHS England): • NHS Pathways developed a new disposition code in 2019 to improve visibility of overdose and suicide attempt cases within the ambulance dispatch queue. • NHS England and Improvement published … (AI summary)
Responded
Lucas Pollard
Concerns: 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.
Response (East of England Ambulance Service NHS Trust): • The Trust stated it would integrate the Critical Care desk function into all three control rooms and share a case study with Critical Care Desk clinicians. • The End … (AI summary)
Responded
Jane Walker
Concerns: The coroner highlighted that paramedics lack access to rapid-acting analgesics, such as mucosal fentanyl lozenges, due to controlled drug legislation, which delays immediate pain relief and can impact patient treatment and extrication.
Response (Drug Misuse Unit): • An NHS England Task & Finish Group on Analgesia has been established to consider recommendations regarding paramedics administering rapid-acting analgesics. • The Task & Finish Group is currently undertaking … (AI summary)
Responded
Fern Foster
Concerns: 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.
Response (NHS England): • NHS England issued updated communications in November 2023, instructing that Category 3 ambulance responses for overdose cases receive further clinical assessment within a set timeframe or be automatically upgraded. … (AI summary)
Response (NARU): • The NARU Clinical Subgroup is scheduled to meet in September 2024 to discuss the management of toxicological incidents and the potential role of methylene blue within HART practice. • … (AI summary)
Response (AACE): • The organisation stated it would not recommend the routine carrying of methylene blue antidote by all ambulances or its inclusion in JRCALC guidance, citing a lack of evidence. • … (AI summary)
Overdue
Margaret Huntley
Concerns: 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.
Response (NHS England): • NHS England confirmed that the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) produces clinical guidelines for paramedics on the recognition and management of adrenal crisis. • NHS England stated … (AI summary)
Response (Association of Ambulance Chief Executives): • The Association of Ambulance Chief Executives is engaging with the Addison’s Disease Self-Help Group and the Pituitary Foundation to provide information to steroid-dependent patients. • The JRCALC guidance for … (AI summary)
Response (NE Ambulance Service): • NEAS has issued clinical alerts and commenced development of a training module on time-critical medications, including steroids, for delivery in 2025/2026. • A refresher training bulletin for Health Advisors … (AI summary)
Responded
Amanda Gainford
Concerns: 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.
Response (NHS England): • NHS England has published the National Framework for healthcare professional ambulance responses, which was last updated in March 2021. • The Framework advises clinicians of the assigned call category … (AI summary)
Overdue
Aran Bradbury
Concerns: 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.
Response (NHS England): • The AMPDS sub-group of the Emergency Call Prioritisation Advisory Group (ECPAG) escalated the issue with 25-C codes to the International Academies for Emergency Dispatch for software amendment. • NHS … (AI summary)
Response (AACE): • The Prevention of Future Deaths report was shared with the National Ambulance Service Medical Directors (NASMeD) for awareness. • AACE liaised with NHS England and was assured that the … (AI summary)
Overdue
Lee Armstrong
Concerns: 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.
Response (NHS England): • NHS England described the existing design of the NHS Pathways system, which is symptom-based and enquires about pre-existing conditions when they may alter assessment outcomes. • NHS England confirmed … (AI summary)
Response (Department of Health and Social Care): • The Department stated that NHS England has a process in place to map 999 call triage system outcomes against ambulance response time categories. • The Department noted that the … (AI summary)
Overdue
Joel Colk
Concerns: 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.
Response (NHS England): • NHS England published an operational procedure in April 2021, requiring further clinical intervention within 30 minutes for declared overdoses and recommending TOXBASE® use. • NHS Pathways introduced a new … (AI summary)
Response (SECAmb): • SECAmb has procedures in place for overdose calls, which include clinical intervention within 30 minutes or automatic upgrade within 40 minutes, and the use of TOXBASE® for risk assessment. … (AI summary)
Responded
Jeffrey Tyler
Concerns: 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.
Response (Welsh Government): • Officials will seek assurance from the Welsh Ambulance Services University National Health Service Trust (WAST) regarding call categorisation processes at a meeting on 24 April 2025. • A new … (AI summary)
Overdue
John England
Concerns: 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.
Response (NHS England): • NHS England will discuss the specific case details within its AMPDS clinical coding sub-group, in collaboration with Priority Dispatch Corp (PDC). • This discussion aims to determine opportunities to … (AI summary)
Responded
Miles Robinson
Concerns: 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.
Overdue
Oscar Keenan
Concerns: 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.
Response (NHS England): • NHS England reviewed Oscar Keenan's case, including an audit of the call, and supported the assessment that the health advisor should have initiated the complex call process. • The … (AI summary)
Response (Unity Health): • The Practice implemented a new process for registering newborn babies, ensuring registration within 24-48 hours of birth notification and providing staff training. • Urgent correspondence and new birth notifications … (AI summary)
Response (South Central Ambulance Service): • The Trust audited the 111 call, identified missed opportunities for a higher disposition, and provided individual feedback and a learning plan to the Health Advisor. • The Trust's Quality … (AI summary)
Response (CQC): • The CQC's local inspection team reviewed the service's risk profile and all held information. • The CQC contacted the provider, Unity Health, which confirmed it launched an investigation and … (AI summary)
Responded
HSSIB safety recommendations(4)
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 …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
The Ambulance Trust has amended its call handling policy to offer more discretion to call handlers as to when they can choose to stay on the phone with a first party caller who has taken an overdose. Propranolol re-coding
Safety Action
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.
Safety Action
Potential under-recognised risk of harm from the use of propranolol
It is recommended that NHS England/NHS Improvement evaluates current approaches to the clinical oversight of overdose calls within ambulance control rooms and leads on work to develop a national framework to describe the requirements for appropriate clinical oversight of overdose …
Safety Recommendation
Health investigations(1)
Scottish Fatal Accident Inquiries(2)
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 higher grading …
Jul 2003
David McClenaghan
That the Scottish Ambulance Service investigate whether a telephony technology solution could be introduced that would assist emergency call handling staff in distinguishing between a silent call and a disconnected call. If such a solution can be identified, it is recommended that it is implemented as soon as possible.
Jan 2026
Other
1 rec
PHSO casework decisions(11)
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.
NHS in England
Oct 2024
P-001051 — North West Ambulance Service NHS Trust
Miss A complained the ambulance service incorrectly categorised her father's 999 call, delayed adrenaline treatment, and failed to use a defibrillator promptly, leading to his death.
NHS in England
Upheld
Apr 2021
P-001421 — North West Ambulance Service NHS Trust
Mrs O complained the 999 call for her father was incorrectly triaged, an ambulance was not sent, and inaccurate information about arrival times was given, potentially delaying treatment and contributing to his death.
NHS in England
Upheld
Jun 2022
P-003783 — South East Coast Ambulance Service NHS Foundation Trust
Mrs V complained the Ambulance Trust completed a welfare call instead of arranging an ambulance for her mother, delaying treatment and contributing to her death.
NHS in England
Aug 2025
P-003777 — Gloucestershire Hospitals NHS Foundation Trust
Mr S complained the Trust failed to provide help as his chest pain deteriorated in the ED waiting room. He also complained the Trust failed to supply requested CCTV footage.
NHS in England
Partly Upheld
Aug 2025
P-004337 — North West Ambulance Service NHS Trust
Miss A complained the Trust failed to identify the cause of her mother's condition or provide appropriate treatment, such as an ECG and immediate hospital transfer, to prevent a cardiac arrest.
NHS in England
Not Upheld
Nov 2025
P-002829 — London Ambulance Service NHS Trust
Mrs B complained the London Ambulance Service delayed answering her 999 call and ambulance arrival for her husband's heart attack, potentially impacting his survival.
NHS in England
Not Upheld
Jul 2024
P-003399 — London Ambulance Service NHS Trust
Miss Y complained the Trust incorrectly categorised a 999 call, causing an ambulance delay that led to her father's avoidable death, and later withdrew a compensation offer.
NHS in England
Mar 2025
P-003492 — London Ambulance Service NHS Trust
Miss U complained a paramedic's inadequate assessment of her stabbed son led to an incorrect hospital transfer delay, possibly affecting his outcome and contributing to his death.
NHS in England
Mar 2025
P-004030 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs W complained the Trust failed to diagnose her husband's leukaemia earlier and delayed sepsis treatment, contributing to his death. She sought acknowledgment, apology, and service improvements.
NHS in England
Partly Upheld
Sep 2025
P-003271 — London Ambulance Service NHS Trust
Miss T complained the Trust incorrectly categorised her son's emergency calls, causing ambulance delays. She believed earlier arrival could have prevented cardiac arrest and saved his life.
NHS in England
Not Upheld
Jan 2025
LGO / SPSO decisions(15)
PSOW-202207867 — Welsh Ambulance Services NHS Trust
Mr W complained that Welsh Ambulance Services NHS Trust had failed to respond to the complaint he submitted in July 2022. The Ombudsman decided that there had been a delay in WAST’s response and this had caused inconvenience and frustration for Mr W. The Ombudsman decided to settle the complaint …
PSOW (Public Services Om…
Health
Mar 2023
PSOW-202105404 — Welsh Ambulance Services NHS Trust
Ms A complained that her late father, Mr B, not being taken to the local hospital by the first ambulance crew adversely affected his treatment and investigation for a suspected stroke. Ms A said that her father’s condition had deteriorated and the following day he was very confused. He had …
PSOW (Public Services Om…
Health
Upheld
Mar 2023
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; …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2022
PSOW-202105080 — Welsh Ambulance Services NHS Trust
Miss D complained about her late father, Mr D’s, treatment by the Health Board and the Trust. She complained that as her father was at the end of life exceptions should have been made to visitor restrictions that were in place due to Covid-19 to allow family to visit him, …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
PSOW-202203456 — Welsh Ambulance Services NHS Trust
Mrs A complained about the late arrival of an ambulance, which led to the sad death of her daughter, Mrs B, at her home. She was also concerned about the attitude of the attending paramedic and the Trust’s failure to respond to her concerns about that in its complaint response. …
PSOW (Public Services Om…
Health
Oct 2022
PSOW-202302966 — Welsh Ambulance Services University NHS Trust
Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, …
PSOW (Public Services Om…
Health
Mar 2025
PSOW-202306104 — Welsh Ambulance Services University NHS Trust
Mrs A complained about a lack of care and treatment by the Welsh Ambulance Services University NHS Trust (“the Trust”) for her son, Mr B, on 14 December 2022. The Ombudsman’s investigation considered the handling of 2 999 calls, the standard of record keeping by the attending paramedic, and whether …
PSOW (Public Services Om…
Health
Mar 2025
20-012-668c — West Midlands Ambulance Service NHS Foundation Trust (20 …
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
201103489 — Scottish Ambulance Service
Ms C complained about an accident she had while being transported by the Scottish Ambulance Service (the service) to a clinic appointment. Ms C said that the driver had taken his finger from the remote-control button operating a stair-lift while Ms C was sitting on it in a wheelchair. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2012
201203148 — Scottish Ambulance Service
Mrs C said that her husband (Mr C) experienced a seizure while driving his taxi, and an ambulance was called. After Mr C was assisted out of the taxi and into the ambulance, Mrs C alleged that the ambulance staff used unreasonable restraint, which resulted in a compression fracture (when …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2013
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 …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2018
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, …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2018
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 …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201703342 — Scottish Ambulance Service
Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2018
202304529 — Scottish Ambulance Service
C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2025