Emergency dispatch algorithm flaws (medication)
54 items
2 sources
Emergency dispatch algorithms failing to account for blood-thinning medication in head injury cases, delaying appropriate response.
Cross-Source Insight
Emergency dispatch algorithm flaws (medication) has been flagged across 2 independent accountability sources:
1 inquiry rec
53 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (53)
Scott Taylor
Concerns: Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition also needs addressing.
Pending
Drew Greaves-Pimblett
Concerns: National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Response: NHS England, through liaison with North West Ambulance Service (NWAS), reports that NWAS has reviewed and amended its Medical Priority Dispatch System (MPDS) guidance for call handlers, introducing clearer protocols …
Responded
Liliane Bowden
Concerns: 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.
Response: 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 …
Responded
William Puplett
Concerns: Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
Response: 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 the …
Responded
Miles Robinson
Concerns: The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.
Overdue
Oscar Keenan
Concerns: 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.
Responded
John England
Concerns: 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.
Responded
Jeffrey Tyler
Concerns: Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.
Responded
Joel Colk
Concerns: NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Responded
Aran Bradbury
Concerns: The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower category response because mental health history overshadowed drug ingestion, delaying critical aid.
Overdue
Amanda Gainford
Concerns: Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.
Responded
Margaret Huntley
Concerns: Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.
Responded
Fern Foster
Concerns: Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes for on-scene administration, potentially preventing deaths.
Overdue
Jane Walker
Concerns: Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Responded
Lucas Pollard
Concerns: A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Responded
Glyn Ackerley
Concerns: The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.
Responded
Rashdah Bhatti
Concerns: Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths from handlers not following MPDS protocols.
Responded
Kenneth Adams
Concerns: The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to dangerous treatment delays.
Responded
Roy Middleton
Concerns: The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
Overdue
Keith Hopwood
Concerns: Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private ambulance was dispatched due to miscategorization, leading to further delays.
Responded
Esma Guzel
Concerns: The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.
Responded
Colin Swain
Concerns: 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.
Overdue
Hannah Royle
Concerns: The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. The public is also misled about the service's diagnostic capabilities.
Overdue
Mark Holden
Concerns: A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.
Overdue
Martin Sullivan
Concerns: The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
Responded
Jack Goodwin
Concerns: 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.
Responded
Zoe Knight
Concerns: Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.
Responded
Mitica Marin
Concerns: 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.
Responded
Ashley Walker
Concerns: A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.
Responded
Alf Rewin
Concerns: No specific safety concerns were identifiable from the provided administrative text.
Responded
Anna Hedman
Concerns: A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.
Overdue
Allan Davies
Concerns: The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly and endangering lives.
Responded
Christopher Williams
Concerns: Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect algorithm use, and communication breakdown causing crucial treatment delays in the emergency department. A dangerous gap exists in the triage system for neurological deficits.
Responded
Alexander Davidson
Concerns: NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Overdue
Terrence Smith
Concerns: The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting emergency response.
Overdue
Marie Millward-Winter
Concerns: Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Responded
Susan Longden
Concerns: The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Responded
Barry Hodges
Concerns: Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.
Responded
Christopher Fields
Concerns: Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical delays in response times for seriously injured patients.
Responded
Caragh Melling
Concerns: The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.
Overdue
Monica Lewis-Hinds
Concerns: The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.
Overdue
Faiza Ahmed
Concerns: No specific concerns are detailed in the provided text, which refers only to the jury's determination.
Responded
Elizabeth Lester
Concerns: The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.
Responded
Yusuf Abdismad
Concerns: Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.
Overdue
Barbara Patterson
Concerns: The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Responded
Hayden Norton
Concerns: Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an emergency protocol.
Overdue
Sharon Butcher
Concerns: Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent a recurring and dangerous systemic failure.
Overdue
Linda Lloyd
Concerns: Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of warfarin on patients.
Overdue
Clare Bain
Concerns: Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.
Responded
Toni Skillington
Concerns: The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.
Overdue
James Sutton
Concerns: The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Overdue
Winston Llewellyn Johns
Concerns: Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Overdue