Emergency services related deaths

PFD Category
Reports: 252 Areas: 59 Earliest: Jan 2016 Latest: 10 Mar 2026

85% response rate (above 62% average). 50% of classified responses show concrete action taken. Reports rose 21% from 38 (2023) to 46 (2024).

Response Status
Responded 214 No Response 3 Historic 31 Pending 4
AI Classification
Action Taken 50%
Action Planned 29%
Noted 14%
Disputed 7%
Based on 122 classified responses
Reports by Quarter
PFD Reports
252 results
Darryl Johnson
Response Pending
2026-0152 10 Mar 2026 Bedfordshire and Luton
Ordnance Survey
Concerns summary Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient outcomes.
Roman Barr
Response Pending
2026-0148 4 Mar 2026 Coventry
NHS England Department of Health and Social Care NHS Pathways/ NHS Digital +2 more
Concerns summary Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.
Yunus Hoque
Response Pending
2026-0113 26 Feb 2026 Manchester South
North West Ambulance Service
Concerns summary NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.
Heather Parkhill
Response Pending
2026-0050 2 Feb 2026 North Wales (East and Central)
Welsh Ambulance Services University NHS…
Concerns summary Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Dorothy Hoyberg
All Responded
2026-0019 14 Jan 2026 Inner North London
Department of Health and Social Care
Concerns summary Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand consistently outstrips capacity.
Action taken summary The Department of Health and Social Care acknowledges ambulance service pressures and refers to the 2025/26 Urgent and Emergency Care Plan and the 10-Year Health Plan, which commit to reducing ambulan
Stephen Taylor
All Responded
2026-0020 14 Jan 2026 Kent and Medway
Vita health Group : Kent and Medway Tal… Kent and Medway Mental Health Trust
Concerns summary Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.
Action taken summary Vita Health Group reviewed and updated its Duty Standard Operating Procedure in November 2025 to mandate same-day actioning of routine referrals and emphasize careful consideration of family informati
Aminata Coulibaly
All Responded
2025-0596 26 Nov 2025 Essex
Chief Constable of Essex Police
Concerns summary Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Action taken summary Essex Police has implemented new training on victim care and information sharing, established a new communication framework with EPUT, and introduced new guidance and a Quality Assurance team in Conta
Liliane Bowden
All Responded
2025-0570 11 Nov 2025 Hampshire, Portsmouth and Southampton
SCAS Legal Services
Concerns summary Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to elderly and vulnerable patients needing prompt attention.
Action taken summary South Central Ambulance Service disputes the report being issued to them, stating the core issue of handover delays lies with hospital trusts. They acknowledge the problem is widespread and explain na
Gunaratnam Kannan
All Responded
2025-0553 31 Oct 2025 Nottingham and Nottinghamshire
East Midlands Ambulance Service Royal College of General Practitioners Nottingham Healthcare NHS Foundation Tr…
Concerns 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.
Action taken summary EMAS has embedded supporting tools like non-conveyance checklists and MCA prompts into their patient record system. They are actively working with system partners to establish robust referral pathways
Lewis Garfield
All Responded
2025-0547 28 Oct 2025 Northamptonshire
Department of Health and Social Care South Central Ambulance Service East Midlands Ambulance Service +1 more
Concerns 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.
Action taken summary EMAS's Incident Review Group has discussed the concerns, and they are now implementing dynamic strategic conveyance daily and proactively initiating rapid handover requests during high demand. They ar
William Puplett
All Responded
2025-0526 10 Oct 2025 North London
International Academies of Emergency Di…
Concerns summary Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
Action taken summary 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 t
Brian Ingram
Partially Responded
2025-0501 8 Oct 2025 Cornwall and the Isles of Scilly
Cornwall Partnership Foundation Trust Lifestar Medical Limited South West Ambulance Service Trust
Concerns summary Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
Action taken summary Lifestar Medical Limited has issued a mandatory memorandum requiring staff to clearly identify their clinical role and facilitate patients and family members remaining together. Cornwall Partnership N
Ricky O’Connell
All Responded
2025-0433 20 Aug 2025 Manchester South
Department of Health and Social Care
Concerns summary Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.
Action taken summary The Department references its June 2025 10-Year Health Plan and Urgent and Emergency Care Plan for 2025/26, which includes nearly £450 million in capital investment for emergency care and new ambulanc
Tracey Ostler
All Responded
2025-0416 7 Aug 2025 Surrey
Epsom General Hospital Department of Health and Social Care Health Services Safety Investigations B… +4 more
Concerns summary A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
Action taken summary The Health Service Safety Investigations Body will launch two national investigations: one into the care of mental health crisis patients in emergency departments starting October 2025, and another in
Kaine Fletcher
All Responded
2025-0383 25 Jul 2025 Nottinghamshire
Nottingham and Nottinghamshire Police East Midlands Ambulance Service Department of Health and Social Care +2 more
Concerns 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 taken summary Nottinghamshire Healthcare NHS Foundation Trust has included ABD signs and symptoms in its Fundamentals of Care training and developed a peer-reviewed quick reference guide for staff. They have also e
Robyn Chambers
All Responded
2025-0370 22 Jul 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in this case.
Action taken summary The Health Board has implemented several initiatives, including a Red2Green project, a Hospital at Home service, and a Corporate Site Clinical Operations Team managing an escalation policy to improve
Kaine Fletcher
No Identified Response
2025-0363 17 Jul 2025 Nottinghamshire
East Midlands Ambulance Service Nottingham and Nottinghamshire Police
Concerns 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.
Miles Robinson
No Identified Response
2025-0340 8 Jul 2025 South London
Emergency Call Prioritisation Advisory … London Ambulance Service NHS Trust
Concerns summary The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.
David Gifford
All Responded
2025-0339 7 Jul 2025 Avon
Association of Ambulance Chief Executiv…
Concerns summary Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Action taken summary The Association of Ambulance Chief Executives (AACE) confirms that the JRCALC committee has decided to review existing abdominal pain and vascular emergencies guidelines. The review will include addin
Thomas Mallinson
All Responded
2025-0333 30 Jun 2025 Cumbria
North West Ambulance Service NHS Trust SSP Health Ltd Cumbria Health Limited +1 more
Concerns summary An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.
Action taken summary Cumbria Health has implemented a new updated escalation policy to manage high workloads and request additional clinical triage assistance, and is in ongoing discussions with the ICB regarding case han
Charlotte Alderson
All Responded
2025-0307 18 Jun 2025 Suffolk
Department of Health and Social Care
Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Action taken summary The Department of Health and Social Care notes that NHS England has no current plans for guidance on a single infection scoring system. It highlights ongoing research funding for sepsis diagnostics an
Valerie Hill
All Responded
2025-0302 13 Jun 2025 South Wales Central
First Minister of Wales
Concerns summary Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.
Action taken summary The First Minister for Wales acknowledges the concerns, outlining the Welsh Government's existing strategic oversight, performance frameworks, and escalation processes for health boards regarding ambu
Oscar Keenan
All Responded
2025-0392 12 Jun 2025 Oxfordshire
South Central Ambulance Service NHS England
Concerns summary Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
Action taken summary NHS England is undertaking a broad review of the entire Paediatric Pathways and is updating the existing sepsis pathway within the NHS Pathways algorithm. Changes to the algorithm are expected to be i
Amy Levy
All Responded
2025-0289 10 Jun 2025 Avon
Avon and Somerset Police College of Policing Surrey Police
Concerns summary Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Action taken summary The College of Policing is updating the national Contact Management Curriculum to explicitly address voicemail guidance in emergency contexts, with rollout by March 2026. They are also supporting the
Edward Wilson
All Responded
2025-0281 5 Jun 2025 Cheshire
North West Ambulance Service
Concerns summary Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
Action taken summary The North West Ambulance Service concluded, following a specialist review, that the treatment afforded to Mr Wilson adhered wholly to national guidelines and there were no contraindications for salbut