Emergency dispatch algorithm flaws (medication)
Emergency dispatch algorithms failing to account for blood-thinning medication in head injury cases, delaying appropriate response.
94 items
6 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
99match
Roy Middleton
The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
Matched on
terms: algorithm, dispatch, emergency, medication
PFD report
77match
Kenneth Adams
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.
Matched on
terms: dispatch, medication
PFD report
77match
John England
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.
Matched on
terms: dispatch, emergency
Inquiry recommendation
74match
MAI-104 - Review Advanced Medical Priority Dispatch System
The Department of Health and Social Care and the National Ambulance Resilience Unit should consider whether the Advanced Medical Priority Dispatch System is fit for purpose and, if it is, whether it can be improved. Particular consideration should be given to how the system prioritises emergency calls.
Matched on
terms: dispatch, emergency
PFD report
73match
James Sutton
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.
Matched on
terms: emergency, medication
PFD report
73match
Christopher Fields
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.
Matched on
terms: algorithm, dispatch
PFD report
73match
Martin Sullivan
The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
Matched on
terms: dispatch, emergency
PFD report
69match
Yusuf Abdismad
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.
Matched on
terms: dispatch, emergency
PFD report
69match
Elizabeth Lester
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.
Matched on
terms: emergency
PFD report
69match
Keith Hopwood
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.
Matched on
terms: algorithm, dispatch
PFD report
69match
Margaret Huntley
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.
Matched on
terms: emergency, medication
PFD report
65match
Marie Millward-Winter
Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Matched on
terms: medication
PFD report
65match
Lucas Pollard
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.
Matched on
terms: dispatch
PFD report
61match
Toni Skillington
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.
Matched on
terms: dispatch
PFD report
61match
Sharon Butcher
There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Matched on
terms: emergency
PFD report
61match
Hayden Norton
After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or that he had been informed of a screening test for aortic aneurysm; furthermore, there was a delay in calling an emergency ambulance because HMP Dartmoor lacked an emergency code protocol.
Matched on
terms: emergency
PFD report
61match
Terrence Smith
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.
Matched on
terms: emergency
PFD report
61match
Christopher Williams
The report highlights an ambulance arriving outside of Trust guidelines, a call handler's failure to escalate the patient's worsening condition and incorrect algorithm use, and a communication breakdown about an arranged hospital bed, potentially delaying treatment.
Matched on
terms: algorithm
PFD report
61match
Amanda Gainford
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.
Matched on
terms: dispatch
PFD report
61match
Lee Armstrong
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.
Matched on
terms: emergency
PFD report
57match
Barbara Patterson
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.
Matched on
terms: dispatch
PFD report
57match
Barry Hodges
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.
Matched on
terms: dispatch
PFD report
57match
Susan Longden
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.
Matched on
terms: algorithm
PFD report
57match
Anna Hedman
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.
Matched on
terms: emergency
PFD report
57match
Esma Guzel
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.
Matched on
terms: algorithm
PFD report
57match
Rashdah Bhatti
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.
Matched on
terms: emergency
PFD report
57match
Jeffrey Tyler
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.
Matched on
terms: dispatch
PFD report
57match
Oscar Keenan
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.
Matched on
terms: algorithm
LGO / SPSO decision
54match
202000766 - Scottish Ambulance Service
C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in...
Matched on
terms: dispatch, emergency
PFD report
53match
Winston Llewellyn Johns
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.
Matched on
classifier match
PFD report
53match
Allan Davies
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.
Matched on
classifier match
PFD report
53match
Hannah Royle
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.
Matched on
classifier match
PFD report
53match
Aran Bradbury
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.
Matched on
classifier match
PFD report
49match
Linda Lloyd
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.
Matched on
classifier match
PFD report
49match
Glyn Ackerley
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.
Matched on
classifier match
PFD report
49match
Jane Walker
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Matched on
classifier match
PFD report
49match
Joel Colk
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.
Matched on
classifier match
PFD report
49match
Miles Robinson
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.
Matched on
classifier match
PHSO casework decision
48match
P-003096 - NHS England
Mrs H complains the NHS Pathways triage system used for all NHS 111 calls is flawed, as it fails to recognise the possibility of sepsis for a caller who reports recent surgery and chemotherapy.
Matched on
terms: flaw
LGO / SPSO decision
46match
201705035 - Scottish Ambulance Service
Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably. Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting for an operation. Mr C said that Mrs...
Matched on
terms: dispatch, emergency
LGO / SPSO decision
46match
201707301 - Scottish Ambulance Service
Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that...
Matched on
terms: dispatch, emergency
LGO / SPSO decision
46match
201708212 - Scottish Ambulance Service
Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance. We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours,...
Matched on
terms: dispatch, emergency
PFD report
45match
Refat Hussain
Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Matched on
classifier match
PFD report
45match
Clare Bain
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.
Matched on
classifier match
PFD report
45match
Monica Lewis-Hinds
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.
Matched on
classifier match
PFD report
45match
Caragh Melling
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.
Matched on
classifier match
PFD report
45match
Alexander Davidson
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.
Matched on
classifier match
PFD report
45match
Alf Rewin
No specific safety concerns were identifiable from the provided administrative text.
Matched on
classifier match
PFD report
45match
Ashley Walker
A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
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classifier match
PFD report
45match
Mitica Marin
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.
Matched on
classifier match