London Ambulance Service NHS Trust

PFD Addressee

Reports: 30 Earliest: Sep 2013 Latest: 8 Jul 2025

Action Taken 46%

Action Planned 30%

Noted 19%

Disputed 5%

Based on 57 classified responses

PFD Reports

30 results

Sabrina Stevenson

2015-0126 30 Mar 2015 London North (Inner)

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.

Action Planned (AI summary) The College of Paramedics commits to writing to NHS ambulance services and HEIs to offer assistance in recruiting paramedics, advising them of revised Paramedic Curriculum Guidance. It will also advise the JRCALC on the recommendation made by the Consultant Gynaecologist and the issue of triage tools. London Ambulance Service secured additional investment of £27.2m to improve response times, increase staffing, and improve productivity and are on track to recruit 850 staff in 2015/16. The LAS has also updated its Serious Incident Policy to ensure staff receive feedback from investigations. NHS England details actions taken with the LAS, including weekly performance reviews, additional funding of £27.2m for 2015/16 to increase staffing and capacity, and improve ambulance response times, with a goal to meet national standards by September 2015. They also cite initiatives to reduce unnecessary vehicle dispatches.

Toni Skillington

Historic (No Identified Response)

2014-0369 31 Jul 2014 London North (Inner)

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.

Rajesh Parkash

Historic (No Identified Response)

2014-0207 8 May 2014 Surrey

Community health care and emergency services related deaths

Concerns summary (AI summary) Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.

Mark Stephen Smith

Historic (No Identified Response)

2013-0268 21 Oct 2013 London (North)

Community health care and emergency services related deaths

Concerns summary (AI summary) Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.

Michael Sweeney

2013-0236 23 Sep 2013 London North (Inner)

Community health care and emergency services related deaths Police related deaths

Concerns summary (AI summary) Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.

Disputed (AI summary) The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance Service. The Medical Director will encourage the adoption of shared terminology and increase awareness in emergency departments. The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and raised the issue of terminology with the national Ambulance Service Mental Health Working Group, which will issue a position statement after consulting the Royal College of Psychiatrists. They will also share their response with the Pan London Emergency Department Consultants Group.