East Midlands Ambulance Service NHS Trust
PFD Addressee
Reports: 28
Earliest: Aug 2013
Latest: 6 Jan 2026
89% 2-year response rate (above 83% average). 56% of classified responses show concrete action taken.
PFD Reports
15 resultsAdam Hussain
All Responded
2026-0002
5 Jan 2026
Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.
Action Planned
(AI summary)
The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS has worked with partners to develop a Sepsis Observation Safety Net, implemented enhanced clinical review processes prior to call transfer, and ceased manual ITK push transfers to NEMS. NEMS has stopped manually pushing calls, implemented a standardised Sepsis Observation Safety Net, and provided additional training and resources to clinicians; furthermore data sharing agreements are in place to share discharge summaries and admission avoidance alerts. The ICB facilitated a system wide After-Action Review, EMAS have stopped the ITK push of calls, a review and redefinition of the existing UCCH service specification has occurred, and analytics team have developed the ability to join up multiple data sets to understand patient journeys.
Jake Hartwright
All Responded
2026-0001
5 Jan 2026
Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.
Action Planned
(AI summary)
The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS clinicians now review all available information prior to transferring calls, and clinically assessed calls are no longer pushed to any EMAS Clinical Assessment Service (CAS). Manual ITK push transfers to NEMS have ceased. NEMS implemented changes to clinical practice and referral processes, including revised sepsis screening tools, enhanced clinical oversight, and improved information sharing with system partners. They have also invested in staff training and equipment to improve the management of complex patient presentations. The ICB facilitated a system-wide After-Action Review, reviewed and redefined the UCCH service specification, and developed the ability to join up multiple data sets to understand the patient journey across the pathway. They also committed to sharing PFD learning and assurance actions across multiple committees and processes.
Gunaratnam Kannan
All Responded
2025-0553
31 Oct 2025
Nottingham and Nottinghamshire
Emergency services related deaths
Suicide
Concerns summary (AI summary)
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, causing confusion over referral responsibilities.
Noted
(AI summary)
EMAS is actively working with local mental health crisis teams to formalise referral pathways and will undertake an After Action Review on 8 January 2026 with all parties involved in the incident. Mental Health Awareness training is also under review for January 2026. The Trust provided bespoke training on the Mental Capacity Act for the Clinical Access Line and Crisis Resolution Home Treatment team. They also developed flow charts to support staff in considering mental capacity and shared these with staff, displaying them in team offices. The RCGP provides context on its role in setting standards and supporting GPs and highlights existing training resources. It suggests system pressures impact GP decision-making and there is an opportunity to address the system aspects of referral processes.
Lewis Garfield
All Responded
2025-0547
28 Oct 2025
Northamptonshire
Emergency services related deaths
Concerns summary (AI summary)
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Noted
(AI summary)
The Trust is implementing dynamic strategic conveyance, directing patients to hospitals outside their usual catchment area. They are also working to implement the 45-minute handover protocol and initiate 'rapid handover' requests during periods of high demand. SCAS investigated the incident, finding one call non-compliant due to documentation errors, and shared learning with the call handler. It details actions taken when a 999 call is received and summarises the call cycle and audit outcomes. The Department acknowledges the concerns and outlines the government's commitment to improving urgent and emergency care. It highlights key actions from the Urgent and Emergency Care Plan and improvements in ambulance response times and handover delays, while noting SCAS has responded in full to the concerns. The hospital has been working through an UEC improvement programme since January 2025, including implementation of the national 45-minute maximum ambulance handover time standard, Frailty SDEC and Trusted Assessor introductions, and NerveCentre pre-arrivals screen. They have increased ambulance handover space and medical pathway by introducing RAU and AAU.
Kaine Fletcher
All Responded
2025-0383
25 Jul 2025
Nottinghamshire
Emergency services related deaths
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.
Action Planned
(AI summary)
The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. The NPCC clinical panel is reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine regarding Acute Behavioural Disturbance. The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. The Department and NHS England are finalising the Co-occurring Mental Health and Substance Use Delivery framework to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.
Kaine Fletcher
All Responded
2025-0363
17 Jul 2025
Nottinghamshire
Emergency services related deaths
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.
Action Taken
(AI summary)
• Nottinghamshire Police has implemented the Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedure since its inception.
• Nottinghamshire Police has consulted with colleagues from EMAS to address the issue of differing positions on the application of the document and suggested several potential remedies.
• EMAS Head of Mental Health advised that their Chief Executive directed that they will not be seeking to implement or refine the existing multi-agency policy. • East Midlands Ambulance Service (EMAS) acknowledged the concerns raised regarding the lack of clarity and shared understanding between agencies on the applicable local policy and working standards for s.136 Mental Health Act detentions.
• EMAS has been operating under a Regional Mental Health conveyance policy since May 2021, developed in consultation with regional Police Forces, Mental Health Trusts, and other stakeholders.
John Howe
All Responded
2024-0339
25 Jun 2024
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.
Action Planned
(AI summary)
MFT has developed a draft "Out of Hours Discharge Avoidance" SOP to manage delayed discharges, which is due to be presented for ratification at the MRI Quality and Safety Committee. They also intend to formally communicate this SOP to external transport providers once ratified across relevant sites. EMAS will continue to contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. The organisation amended inaccuracies in the Serious Incident Review (SIR) and reshared it with relevant safeguarding boards and the Manchester Foundation Trust Safeguarding Team. They have implemented a system to ensure investigations are completed in a timely manner and are reviewing processes for discharges to 'out of area' localities.
Liam McCarlie
All Responded
2024-0337
24 Jun 2024
Northamptonshire
Emergency services related deaths
Suicide
Concerns summary (AI summary)
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Action Taken
(AI summary)
Northamptonshire ICB and Northamptonshire Healthcare NHS Foundation Trust (NHFT) have put in place a 24/7 mental health crisis service, run by NHFT, to support the ambulance service with access to mental health practitioners within an hour of a call. EMAS also includes mental health workers in their call center, with a 24/7 service.
Alfie Stone
All Responded
2022-0013
14 Jan 2022
Northamptonshire
Child Death
Emergency services related deaths
Concerns summary (AI summary)
Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
Action Planned
(AI summary)
EMAS will be sharing updated guidance, national PGD and learning from this PFD across the Ambulance Pharmacists Network. Updated guidance and training package is being developed and will be rolled out during 2022/23 which will include the option for clinicians to administer buccal midazolam to adults (18 years and over) who present with convulsive status epilepticus when it is not available within the home as a prescribed medication.
Olive Johnson
All Responded
2019-0031
24 Jan 2019
Lincolnshire
Emergency services related deaths
Concerns summary (AI summary)
Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call regrading.
Action Planned
(AI summary)
EMAS acknowledges exceeding response times and states that additional funding was agreed to address this. The funding will be used for clinical staff, ambulances, and other resources to improve response times and consistency across the East Midlands.
Diana Gudgeon
All Responded
2019-0015
9 Jan 2019
Northamptonshire
Emergency services related deaths
Concerns summary (AI summary)
Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.
Action Taken
(AI summary)
The ambulance service uses the Advanced Medical Priority Dispatch System (AMPDS) and is actively recruiting staff to a newly created Clinical Hub to address call volume, with some staff already trained and operational. The Capacity Management and Escalation Plan is reviewed annually. The 111 service uses NHS Pathways software, updated twice yearly, with staff training covering sepsis, including a Distance Learning Pack with a formal assessment, and NICE Guidance on feverish illness. Clinicians receive sepsis risk stratification tools and are notified of a free online course on Sepsis in Primary Care.
Dipa Lad
All Responded
2017-0019
31 Jan 2017
Nottinghamshire
Community health care and emergency services related deaths
Concerns summary (AI summary)
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.
Action Taken
(AI summary)
EMAS reviewed its procedures and provided guidance for clinicians dealing with cardiac arrest patients, including additional guidance around futility aligned with BMA, RCUK, and RCN guidance. All clinical staff receive annual refresher training including resuscitation assessments, and dynamic risk assessments are performed for CPR technique.
Stuart Knight
All Responded
2015-0385
22 Sep 2015
Central Lincolnshire
Community health care and emergency services related deaths
Concerns summary (AI summary)
Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Action Taken
(AI summary)
EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for high clinical need cases.
Sally Perrons
All Responded
2014-0158
9 Apr 2014
Nottinghamshire
Community health care and emergency services related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text for summarization.
Action Planned
(AI summary)
The National Ambulance Sector will require the use of either a digital ETC02 monitoring device or full waveform capnography for every intubation with immediate effect. Waveform capnography will be considered the gold standard and the sector is committed to having this in place on every responding vehicle crewed by a paramedic by July 2017.
Lucy Hannah Rose Bailey
All Responded
2013-0176
6 Aug 2013
Rutland & North Leicestershire
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Action Taken
(AI summary)
The South Central Ambulance Service has updated its clinical practice guidance on the management of shoulder dystocia, incorporating advice from specialists in obstetrics and midwifery, and issued it to Medical Directors of Ambulance Trusts across the UK.