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
Clear
PFD Reports
199 results
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
Kent and Medway Mental Health Trust Vita health Group : Kent and Medway Tal…
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
Nottingham Healthcare NHS Foundation Tr… Royal College of General Practitioners East Midlands Ambulance Service
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
University Hospitals of Northamptonshire 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
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
Health Services Safety Investigations B… Surrey and Borders NHS Foundation Trust South East Coast Ambulance Service +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
Department of Health and Social Care East Midlands Ambulance Service Nottingham and Nottinghamshire Police +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
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
Department of Health and Social Care 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
NHS England South Central Ambulance Service
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
College of Policing Surrey Police Avon and Somerset 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
Brian Garrick
All Responded
2025-0271 30 May 2025 The County of Devon, Plymouth and Torbay
Department of Health and Social Care
Concerns summary Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.
Action taken summary The DHSC stated that NHS England is working with systems to reduce ambulance handover delays, aiming for hospital handovers within 15 minutes and none longer than 45 minutes, supported by increased NH
Jeanette Sidlow Beech
All Responded
2025-0279 29 May 2025 North Wales (East and Central)
Welsh Government
Concerns summary Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.
Action taken summary The Welsh Government has placed all health boards in Wales under escalation for urgent and emergency care, with Betsi Cadwaladr University Health Board in special measures. It has provided an addition
Paul Alexander
All Responded
2025-0244 27 May 2025 West Yorkshire West
West Yorkshire Police
Concerns summary Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Action taken summary West Yorkshire Police states that an escalation process has been developed following partnership discussions and incident reviews, and they continue to work closely with partners to identify and share
Sophie Cotton
All Responded
2025-0246 27 May 2025 Durham and Darlington
Officer of the College of Policing Durham Constabulary
Concerns summary Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.
Action taken summary Durham Constabulary's Deputy Chief Constable confirms that a full review of the case and police actions has been undertaken, with the detailed outcomes and actions provided in an attached response. Th
James Smith
All Responded
2025-0224 12 May 2025 Cornwall and Isles of Scilly
Department of Health and Social Care
Concerns summary Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency care.
Action taken summary The DHSC published a revised policy framework for the Better Care Fund on January 31, 2025, which took effect on April 1, 2025. This fund, investing £9 billion in 2025-26, aims to integrate health and
John England
All Responded
2025-0221 9 May 2025 Cornwall and Isles of Scilly
NHS England
Concerns summary The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential surgical emergency.
Action taken summary NHS England states its Emergency Clinical Advisory Group is developing new national guidance for ambulance services on clinical governance. The specific details of Mr England's case will be discussed
Paul Burke
All Responded
2025-0215 2 May 2025 Hertfordshire
Department of Health and Social Care
Concerns summary Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose a risk of future deaths.
Action taken summary The DHSC will publish its 10-Year Health Plan in Summer 2025 and has set new headline ambitions for the NHS, including reducing ambulance handover times and A&E waits. They are committing almost £450