Emergency services related deaths
PFD Category
Reports: 257
Areas: 59
Earliest: Jan 2016
Latest: 3 Apr 2026
87% response rate (above 63% average). 44% of classified responses show concrete action taken. Reports rose 21% from 38 (2023) to 46 (2024).
PFD Reports
257 resultsGareth Bickerstaff
Historic (No Identified Response)
2019-0029
25 Jan 2019
Manchester (North)
Joint Royal Colleges Ambulance Liaison …
Concerns summary (AI summary)
Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially begins.
Olive Johnson
All Responded
2019-0031
24 Jan 2019
Lincolnshire
East Midlands Ambulance Service
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.
Gail Bailey
Historic (No Identified Response)
2019-0027
23 Jan 2019
Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary (AI summary)
A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Mark Harris
Historic (No Identified Response)
2019-0023
17 Jan 2019
Suffolk
Emergency Operation Centre Norwich
Melbourne Ambulance Station
Concerns summary (AI summary)
Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
Diana Gudgeon
All Responded
2019-0015
9 Jan 2019
Northamptonshire
111 Service
East Midlands Ambulance Service
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.
Kevan Funnell
All Responded
2024-0095
27 Feb 2018
West Sussex, Brighton and Hove
South East Coast Ambulance Service
Concerns summary (AI summary)
No specific concerns for future deaths were detailed in the provided text.
Action Planned
(AI summary)
South East Coast Ambulance Service is working with commissioners in a jointly commissioned demand and capacity review, intended to better align resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards. The recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring.
Faiza Ahmed
All Responded
2016-0600
20 Jan 2016
Inner North London
Department for Work and Pensions
London Ambulance Service NHS Trust
Metropolitan Police
Concerns summary (AI summary)
No specific concerns are detailed in the provided text, which refers only to the jury's determination.
Action Planned
(AI summary)
The DWP believes its processes were followed correctly but will issue a reminder to all staff about guidance related to suicidal ideation. Following the incident, the involved crew undertook Reflective Learning, and a Clinical Update reinforcing the assessment of Capacity was published. A new Operational Management Structure was implemented, including Stakeholder Engagement Manager and Quality Assurance & Governance Manager roles, as well as funding for Mental Health Nurses in the control room. The Metropolitan Police will ensure that the future structure and resourcing model of Sapphire teams meets the demands of increased reporting levels and promotes a supportive working environment, and invest in training for first responders and investigators.