Jack Shields
PFD Report
All Responded
Ref: 2025-0122
All 1 response received
· Deadline: 30 Apr 2025
Coroner's Concerns (AI summary)
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.
View full coroner's concerns
The MATTER OF CONCERN is: –
At 00:36am on 28th April 2024 the first ambulance arrived at the scene, which was 1 hour and 22 minutes following the initial call being received. This was a technician led dual crew ambulance provided by NERAMS - a third-party provider. The crew informed the Emergency Operations Centre at 00:52am on 28th April 2024 that an amber request for paramedic assistance was required. A rapid response paramedic arrived at the scene at 01:07am on 28th April 2024. Unfortunately, Jack deteriorated into a cardiac arrest and despite resuscitative efforts, he was declared deceased at 02:27am on 28th April 2024.
The evidence was clear that Jack’s condition at the time of the first ambulance arrival at 00:36am was such that a higher priority backup should have been requested. Jack was symptomatic of cardiogenic shock with descending blood pressures, shortness of breath, nausea and vomiting, and required the highest priority backup of Cat 1 (Peri Arrest).
I am concerned that the crew should have recognised the deteriorating condition when considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a backup request may have led to rapid stabilisation and transportation to definitive care. I shall be glad to be told of any learning arising from this death and timescales and results of your review.
At 00:36am on 28th April 2024 the first ambulance arrived at the scene, which was 1 hour and 22 minutes following the initial call being received. This was a technician led dual crew ambulance provided by NERAMS - a third-party provider. The crew informed the Emergency Operations Centre at 00:52am on 28th April 2024 that an amber request for paramedic assistance was required. A rapid response paramedic arrived at the scene at 01:07am on 28th April 2024. Unfortunately, Jack deteriorated into a cardiac arrest and despite resuscitative efforts, he was declared deceased at 02:27am on 28th April 2024.
The evidence was clear that Jack’s condition at the time of the first ambulance arrival at 00:36am was such that a higher priority backup should have been requested. Jack was symptomatic of cardiogenic shock with descending blood pressures, shortness of breath, nausea and vomiting, and required the highest priority backup of Cat 1 (Peri Arrest).
I am concerned that the crew should have recognised the deteriorating condition when considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a backup request may have led to rapid stabilisation and transportation to definitive care. I shall be glad to be told of any learning arising from this death and timescales and results of your review.
Responses
Action Taken
Following an investigation into the death of Jack Matthew Shields, The Nerams Group dismissed one employee for gross negligence and terminated another for unrelated reasons. They refreshed competency assessments and CPD for non-registered healthcare professionals reading 12 lead ECGs and circulated information on available backup categories to all staff. (AI summary)
Following an investigation into the death of Jack Matthew Shields, The Nerams Group dismissed one employee for gross negligence and terminated another for unrelated reasons. They refreshed competency assessments and CPD for non-registered healthcare professionals reading 12 lead ECGs and circulated information on available backup categories to all staff. (AI summary)
View full response
Dear HM Coroner, I write to you in response to your request for further information, lessons learned and mitigations following the death of Jack Matthew Shields Deceased on the 27th of April 2024. We were notified of this event from the Northeast Ambulance Service following a concern raised against an employee of ours at the time. The concerns surrounded the lack of identification of the clinical presentation of the patient at the time of attendance and that a higher category of backup should have been requested. The crew consisted of a double Technician crew; (Advanced Technician) and
(Emergency Care Technician), both of whom held a level of qualification which should have allowed them to have recognised the presentation and initiate treatment. Upon investigation of the events, it was identified that there were significant failings on the part of which could not be rationally justified. was the senior clinician who was responsible for the patient care. During the hearing, was still unable to identify the concerning features of the case and key features of the ECG when shown to him again, as a result of this and due to another unrelated identified clinical concern, was dismissed due to gross negligence. was also terminated due to unrelated employment reasons. Appropriate referrals to both the Northeast Ambulance Service to allow them to monitor his ongoing employment on their contracts should he attempt to apply for them or work for a different company as well as statutory notifications to the CQC were made immediately following this incident investigation. Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.
Should you require more information, please do not hesitate to contact me directly.
(Emergency Care Technician), both of whom held a level of qualification which should have allowed them to have recognised the presentation and initiate treatment. Upon investigation of the events, it was identified that there were significant failings on the part of which could not be rationally justified. was the senior clinician who was responsible for the patient care. During the hearing, was still unable to identify the concerning features of the case and key features of the ECG when shown to him again, as a result of this and due to another unrelated identified clinical concern, was dismissed due to gross negligence. was also terminated due to unrelated employment reasons. Appropriate referrals to both the Northeast Ambulance Service to allow them to monitor his ongoing employment on their contracts should he attempt to apply for them or work for a different company as well as statutory notifications to the CQC were made immediately following this incident investigation. Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.
Should you require more information, please do not hesitate to contact me directly.
Sent To
- Nerams Group
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Apr 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 15th January 2025 I commenced an Investigation into the death of Mr Jack Matthew Shields, who was born on 17th May 1994 and who died at , Sunderland on 28th April 2024 aged 29 years. The Investigation concluded at the end of the Inquest on 25th February 2025.
The narrative conclusion of the Inquest was ‘Deterioration of a heart condition whilst an ambulance allocation was significantly delayed following a missed opportunity to assign an earlier available ambulance’.
The medical cause of death was: - Ia Heart Failure II Aortic Dissection
The narrative conclusion of the Inquest was ‘Deterioration of a heart condition whilst an ambulance allocation was significantly delayed following a missed opportunity to assign an earlier available ambulance’.
The medical cause of death was: - Ia Heart Failure II Aortic Dissection
Circumstances of the Death
Jack Matthew Shields was a 29 year old male with a past medical history outlining extensive heart conditions. Jack had three previous open-heart surgeries including aortic dissection.
On the evening of 27th April 2024 Jack experienced shortness of breath, and his mother called 999 at 23:14hrs that night. This was categorised as Cat 2. Following a clinician callback at 00:27am on 28th April 2024 an ambulance was allocated at 00:31am and arrived on scene at 00:36am. This was over an hour later than the national average response time for Cat 2 patients.
Page 2 of 3 It later transpired after an investigation by NEAS following Jack’s death, that another ambulance had been available at 23:24am and, if allocated, would have arrived on scene at 23:36hrs on 27th April 2024.
At 00:52 on 28th April 2024 an amber backup request was made, and a rapid response paramedic arrived at 01:07am. A third crew arrived at 01:36am, but Jack had already deteriorated into a cardiac arrest. The backup request was incorrectly categorised by the crew as Jack’s condition was clearly deteriorating, and he was acutely unwell due to reducing blood pressure over a short time, tachycardia and an ECG revealed an ST-Elevated Myocardial Infarction. He required a higher priority backup.
Jack died at his home address of , Sunderland despite extensive resuscitation attempts with his death declared at 02:27am on 28th April 2024.
On the evening of 27th April 2024 Jack experienced shortness of breath, and his mother called 999 at 23:14hrs that night. This was categorised as Cat 2. Following a clinician callback at 00:27am on 28th April 2024 an ambulance was allocated at 00:31am and arrived on scene at 00:36am. This was over an hour later than the national average response time for Cat 2 patients.
Page 2 of 3 It later transpired after an investigation by NEAS following Jack’s death, that another ambulance had been available at 23:24am and, if allocated, would have arrived on scene at 23:36hrs on 27th April 2024.
At 00:52 on 28th April 2024 an amber backup request was made, and a rapid response paramedic arrived at 01:07am. A third crew arrived at 01:36am, but Jack had already deteriorated into a cardiac arrest. The backup request was incorrectly categorised by the crew as Jack’s condition was clearly deteriorating, and he was acutely unwell due to reducing blood pressure over a short time, tachycardia and an ECG revealed an ST-Elevated Myocardial Infarction. He required a higher priority backup.
Jack died at his home address of , Sunderland despite extensive resuscitation attempts with his death declared at 02:27am on 28th April 2024.
Copies Sent To
North East Ambulance Services and their Solicitors
Care Quality Commission
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
Staff training and development
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Staff training and development
Balancing vulnerability with professional curiosity
Southport Inquiry
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.