Emergency services related deaths

Concerns summary The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.

Concerns summary Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of safety protocols, with multiple reported incidents despite no identified device defects.

Concerns summary Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he could contact someone for assistance, a script deficiency later partially addressed.

Concerns summary Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to her family or GP, leaving a vulnerable patient unmonitored.

Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.

Concerns summary Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.

Concerns summary Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.

Concerns summary Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.

Concerns summary Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service resources.

Concerns summary The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national issue," but provides no specific details on remaining concerns or identified risks.

Concerns summary The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not adequately reassessed.

Concerns summary Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.

Concerns summary A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; this is a recurring issue, reducing survival prospects.

Concerns summary Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for vulnerable patients.

Concerns summary A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.

Concerns summary Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.

Concerns summary GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.

Concerns summary West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.

Concerns summary Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of fire service capabilities for vehicle lifting, hindering decision-making.

Concerns summary The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a safety flaw.

Concerns summary Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.

Concerns summary The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.

Concerns summary Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways are compromised. There's also no pathway for updating prison staff or facilitating dialogue with hospital EDs on call categorisation.

Concerns summary The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.

Concerns summary High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting outcomes in future cases.