William Puplett
PFD Report
All Responded
Ref: 2025-0526
All 1 response received
· Deadline: 5 Dec 2025
Response Status
Responses
1 of 1
56-Day Deadline
5 Dec 2025
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Consideration by the International Academies of Emergency Dispatch to add the following questions when dealing with a patient out of hospital or at home with a tracheostomy tube where there are difficulties with the tracheostomy tube and the patient is experiencing difficulty in breating. “Have you got suction equipment available and is there someone with the patient who is able to use the suction equipment ? And where the answer is no to either or both the result should be a Category 1 response .
Responses
The IAED states the emergency medical dispatcher was compliant with existing protocol and correctly assigned the appropriate dispatch code. It argues the caller was asked about special equipment and the answer reasonably assumed none was available, implicitly rejecting the need for additional specific questions about suction equipment.
AI summary
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© 2026 IAED CONFIDENTIAL Origin: 19 Dec 2025 3
International Academies of Emergency Dispatch Request for Secondary Case Review Bryon Schultz IAED Independent Case Review 6 January 2026
Requested by: Mr. Andrew Walker Re: Independent Call Audit Incident Reference: Agency Contact:
London Ambulance Service NHS Trust Quality Assurance Manager
IAED Reviewer(s): , IAED Medical SME, Medical Council of Standards CC:
Protocol Logic Version: 14.0.222
ProQA Program: 5.1.1.50 AQUA IPR: NA Review Date(s): 12/18/ 2025 Incident Date(s): 11/09/2024
This case involves a 999 call requested to be independently reviewed by the IAED. The time stamps reported here reflect the information obtained from the ProQA sequences report and do not precisely align with the audio record. The total time recorded in the software records is significantly less than the total audio record times. This may occur if information was obtained before ProQA was opened and then entered rapidly without processing the previous interrogation time.
Observations: The audio recording for this case was 4 minutes and 33 seconds. The ProQA case sequence was 1 minutes and 16 seconds.
This 9-9-9 call was made by the patient's partner. Local Dispatch on Demand protocol was used (awake and breathing?) and both questions were answered as Yes. The EMD then asked, “Ok, tell me exactly what happened.” The caller stated her partner “…has a tracheostomy and is waiting to go in for a laryngectomy and now has really trouble breathing tonight”. The line disconnected after the address was asked. The EMD rang the caller back immediately and was reconnected with the caller. The address and phone number were obtained and verified. The EMD continued with Case Entry questions and determined the patient was awake and breathing. The EMD correctly selected MPDS Protocol 6 (Breathing Problems). During Key Questioning, the caller described the patient as responding normally (alert) and being in obvious distress. The caller's response to the Key Question “Does he have any special equipment or instructions to treat this?” was that they had a “nebulizer and that sort of thing.” The EMD informed the caller that the response would be about an hour. The caller was provided with the instruction to call back if the patient's condition worsened. The ProQA sequence indicates the use of the Urgent Disconnect
© 2026 IAED CONFIDENTIAL Origin: 19 Dec 2025 4
option to end the call. This likely explains why no additional Case exit instructions were provided.
Findings: This reviewer found this case to be compliant with the IAED performance standards. The EMD correctly identified the patient as being in obvious respiratory distress. The final MPDS code assignment of 6-D-5 (Breathing Problems/Tracheostomy (obvious distress) was correct and appropriate.
The caller was asked about having any special equipment to treat the complaint of tracheostomy blockage.
The caller's answer did not include the availability of any special equipment, and it was reasonably assumed, by the answer provided, that such equipment was not available.
Remarks: Judging from the audio record, this reviewer has determined the EMD was compliant to protocol. The resulting dispatch code, 6-D-5, was correct and appropriate for this call. The general resource assignment recommendation for this DELTA level code is an immediate, ALS-level, Hot (lights and sirens) response. However, actual response assignments are locally determined.
It should also be noted that staying on the line when dealing with an unstable patient in obvious distress is highly recommended by the IAED, as is an immediate response assignment. However, the situation in the communications center at the time this call was taken is unknown to this reviewer.
Finally, it’s clear that a delayed response to this very ill patient was likely a factor in the poor outcome of this case, despite the correct response code being generated.
Subject Matter Expert-Medical, IAED Medical Council of Standards
International Academies of Emergency Dispatch Request for Secondary Case Review Bryon Schultz IAED Independent Case Review 6 January 2026
Requested by: Mr. Andrew Walker Re: Independent Call Audit Incident Reference: Agency Contact:
London Ambulance Service NHS Trust Quality Assurance Manager
IAED Reviewer(s): , IAED Medical SME, Medical Council of Standards CC:
Protocol Logic Version: 14.0.222
ProQA Program: 5.1.1.50 AQUA IPR: NA Review Date(s): 12/18/ 2025 Incident Date(s): 11/09/2024
This case involves a 999 call requested to be independently reviewed by the IAED. The time stamps reported here reflect the information obtained from the ProQA sequences report and do not precisely align with the audio record. The total time recorded in the software records is significantly less than the total audio record times. This may occur if information was obtained before ProQA was opened and then entered rapidly without processing the previous interrogation time.
Observations: The audio recording for this case was 4 minutes and 33 seconds. The ProQA case sequence was 1 minutes and 16 seconds.
This 9-9-9 call was made by the patient's partner. Local Dispatch on Demand protocol was used (awake and breathing?) and both questions were answered as Yes. The EMD then asked, “Ok, tell me exactly what happened.” The caller stated her partner “…has a tracheostomy and is waiting to go in for a laryngectomy and now has really trouble breathing tonight”. The line disconnected after the address was asked. The EMD rang the caller back immediately and was reconnected with the caller. The address and phone number were obtained and verified. The EMD continued with Case Entry questions and determined the patient was awake and breathing. The EMD correctly selected MPDS Protocol 6 (Breathing Problems). During Key Questioning, the caller described the patient as responding normally (alert) and being in obvious distress. The caller's response to the Key Question “Does he have any special equipment or instructions to treat this?” was that they had a “nebulizer and that sort of thing.” The EMD informed the caller that the response would be about an hour. The caller was provided with the instruction to call back if the patient's condition worsened. The ProQA sequence indicates the use of the Urgent Disconnect
© 2026 IAED CONFIDENTIAL Origin: 19 Dec 2025 4
option to end the call. This likely explains why no additional Case exit instructions were provided.
Findings: This reviewer found this case to be compliant with the IAED performance standards. The EMD correctly identified the patient as being in obvious respiratory distress. The final MPDS code assignment of 6-D-5 (Breathing Problems/Tracheostomy (obvious distress) was correct and appropriate.
The caller was asked about having any special equipment to treat the complaint of tracheostomy blockage.
The caller's answer did not include the availability of any special equipment, and it was reasonably assumed, by the answer provided, that such equipment was not available.
Remarks: Judging from the audio record, this reviewer has determined the EMD was compliant to protocol. The resulting dispatch code, 6-D-5, was correct and appropriate for this call. The general resource assignment recommendation for this DELTA level code is an immediate, ALS-level, Hot (lights and sirens) response. However, actual response assignments are locally determined.
It should also be noted that staying on the line when dealing with an unstable patient in obvious distress is highly recommended by the IAED, as is an immediate response assignment. However, the situation in the communications center at the time this call was taken is unknown to this reviewer.
Finally, it’s clear that a delayed response to this very ill patient was likely a factor in the poor outcome of this case, despite the correct response code being generated.
Subject Matter Expert-Medical, IAED Medical Council of Standards
Report Sections
Investigation and Inquest
On the 11 November 2024 I commenced an investigation into the death of, William John Puplett, aged 78. The investigation concluded at the end of the inquest on 01 October 2025. The conclusion of the inquest was Consequences of a blocked tracheostomy tube at home where there was no working suctioning equipment. The medical cause of death was 1a Hypoxic Brain Injury, 1b Respiratory arrest from block tracheostomy tube, II Laryngeal cancer
Circumstances of the Death
On the 9th November 2024 William John Puplett awoke in respiratory distress as his tracheostomy tube had become blocked and an ambulance was called at 5.06 hrs. The ambulance arrived at 6.45 to find that Mr Puplett had no pulse and had stopped breathing. Mr Puplett did not have a working suction unit at his home when he needed it on the 9th November 2024. Mr Puplett was taken to hospital where, having suffered a significant hypoxic injury, and despite treatment he died the same day. It is likely that had the ambulance arrived before 6.20 when Mr Puplett' s heart stopped, he may not have died when he did.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.