Emergency services related deaths

Concerns summary The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective treatment.

Concerns summary Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was ineffective safety officer monitoring, poor leadership and risk assessment during restraint, and insufficient paramedic input.

Concerns summary There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.

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 Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.

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 Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.

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 Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.

Concerns summary A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full assessment, indicating a need for procedure review and revision.

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 Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill 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.