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
Raymond Gillespie
Historic (No Identified Response)
2022-0154 25 May 2022 North Wales (East & Central)
Welsh Ambulance NHS Foundation Trust an…
Concerns summary Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.
Michael Wysockyj
All Responded
2022-0153 24 May 2022 Norfolk
Queen Elizabeth Hospital King’s Lynn NH…
Concerns summary Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by staff, risking missed diagnoses.
Raphael Gill
All Responded
2022-0131 27 Apr 2022 South London
London Ambulance Services NHS Trust
Concerns summary Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.
Ashleigh Timms
All Responded
2022-0123 26 Apr 2022 East London
British Standards Institution London Fire Brigade Sequence Care Group +1 more
Concerns summary Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
John Murphy
All Responded
2022-0126 22 Apr 2022 Manchester South
Department of Health and Social Care
Concerns summary Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.
Robert Murray
All Responded
2022-0093 23 Mar 2022 East Sussex
Association of Ambulance Chief Executiv…
Concerns summary There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.
Colin Swain
Historic (No Identified Response)
2022-0076 10 Mar 2022 Suffolk
Priority Dispatch Corporation
Concerns summary CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a need for clearer guidance on managing such scenarios.
Josephine Barker
Partially Responded
2022-0077 7 Mar 2022 County of Surrey
NHS England South East Coast Ambulance Service
Concerns summary Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate system for prioritizing high-risk calls and monitoring patient deterioration.
Sarah Gilbert-Jones
All Responded
2022-0037 4 Feb 2022 South Wales Central
Welsh Ambulance NHS Trust
Concerns summary Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Barbara Young
All Responded
2022-0027 28 Jan 2022 Gwent
Wales Ambulance Service NHS Trust
Concerns summary A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.
Adam Stone
All Responded
2022-0026 27 Jan 2022 Birmingham and Solihull
NHS Pathways and Advanced Medical Prior… Association of Ambulance Chief Executiv… College of Paramedics
Concerns summary Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent medical care.
Alfie Stone
All Responded
2022-0013 14 Jan 2022 Northamptonshire
East Midlands Ambulance Service
Concerns 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.
Shaun Mansell
All Responded
2021-0383 1 Nov 2021 Stoke-on-Trent and North Staffordshire Coroner’s Court
Royal Stoke University Hospital and NHS…
Concerns summary Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.
Leon Briggs
All Responded
2021-0330 4 Oct 2021 Bedfordshire and Luton
Association of Ambulance Chief Executiv… Bedfordshire Police National Police Chiefs’ Council +1 more
Concerns summary The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Richard Boateng
All Responded
2021-0335 28 Sep 2021 South London
College of Policing NHS England London Ambulance Service
Concerns summary Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Robert Walaszkowski
Historic (No Identified Response)
2021-0325 27 Sep 2021 East London
Patient Transport UK Ltd
Concerns summary A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.
Uyapo Theodore Hayunga-Macha
All Responded
2021-0314 20 Sep 2021 Liverpool and Wirral
North West Ambulance Service Wirral University Teaching Hospital Cheshire Wirral Partnership
Concerns summary A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.
Sheldon Marshall
All Responded
2021-0276 20 Aug 2021 Surrey
Mayday Group
Concerns summary Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management during air ambulance repatriations pose risks of future deaths.
Steve Cooke
All Responded
2021-0266 8 Aug 2021 Mid Kent and Medway
South East Coast Ambulance Service
Concerns summary Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell patient not being located.
Pauline Allison
All Responded
2021-0269 3 Aug 2021 West Sussex
British Medical Association and Sussex …
Concerns summary Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant safety concern.
Nadeem Ahmed
All Responded
2021-0232 8 Jul 2021 East London
London’s Air Ambulance London Ambulance Service NHS Trust
Concerns summary Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially due to a lack of shared training or checklists between paramedics.
Peggy Copeman
All Responded
2021-0182 28 May 2021 Norfolk
Premier Rescue Ambulance Services
Concerns summary Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff member was CPR trained, violating policy.
Parys Lapper
All Responded
2021-0148 10 May 2021 West Sussex
NHS England
Concerns summary A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.
Martin Sullivan
All Responded
2021-0056 2 Mar 2021 Manchester South
NHS England and NHS Stockport Clinical …
Concerns summary The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
Jaden Francois-Espirit
All Responded
2021-0048 22 Feb 2021 Inner North London
London Fire Brigade
Concerns summary The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.