Emergency responder equipment training
151 items
2 sources
Lack of adequate training for emergency responders on the circumstances and importance of using issued recording equipment.
Cross-Source Insight
Emergency responder equipment training has been flagged across 2 independent accountability sources:
45 inquiry recs
106 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (45)
BAHA-14 — Communicating Sight Deprivation Reasons
Recommendation: JDP 1-10 should include guidance that where practicable CPErS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be included in mission specific language training.
Gov response: Accepted. Guidance on communicating with CPErS about sight deprivation has been added, including language training requirements.
Accepted
Delivered
14 — Prohibit handcuffing behind back while seated
Recommendation: The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.
Gov response: The government has communicated to all IRC and contracted service provider staff that the technique of handcuffing behind backs whilst seated is not permitted.
Accepted
Delivered
CR1 — Network flexing risk mitigation
Recommendation: Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard must ensure the effectiveness of measures in mitigating them (including …
Response Pending
CR10 — Equipment and techniques development
Recommendation: HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist in search and rescue operations.
Response Pending
CR15 — Joint training exercises plan
Recommendation: HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English Channel and elsewhere.
Response Pending
FENN-15 — Modify London Underground fire equipment to London Fire Brigade standards
Recommendation: London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Unknown
FENN-19 — Ensure water gas fire extinguishers are safe near electrical equipment
Recommendation: Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
Unknown
FENN-20 — Produce and maintain up-to-date station plans in LFB-agreed locations
Recommendation: In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
Unknown
FENN-31 — Review LFB protective clothing provision, especially gloves, for personnel
Recommendation: The London Fire Brigade shall review the provision of protective clothing for its personnel, and in particular gloves, in the light of the injuries sustained by fire-fighters at King's Cross.
Unknown
P1-26 — Equipment for BA communication in high-rise buildings
Recommendation: The LFB urgently take steps to obtain equipment that enables firefighters wearing helmets and breathing apparatus to communicate with the bridgehead effectively, including when operating in high-rise buildings.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-27 — Command support system operational on all units
Recommendation: Urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-34 — Equip fire services with smoke hoods
Recommendation: All fire and rescue services be equipped with smoke hoods to assist in the evacuation of occupants through smoke-filled exit routes.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-7 — Equip fire services to receive electronic plans
Recommendation: All fire and rescue services be equipped to receive and store electronic plans and to make them available to incident commanders and control room managers.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P2-35 — Consider higher power radios for breathing apparatus
Recommendation: That fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC is surveying fire and rescue services to understand what arrangements are currently in place at a local …
Accepted
In progress
P2-36 — Provide firefighters with digital radios
Recommendation: That all fire and rescue services give consideration to providing all firefighters with digital radios. (113.60)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. See recommendation 35.
Accepted
In progress
P2-37 — Train firefighters on communications loss response
Recommendation: Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. (113.61)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the content of national operational guidance and is surveying fire and rescue services to establish …
Accepted
In progress
P2-38 — Provide water supply system training to all firefighters
Recommendation: That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the national operational guidance and is surveying fire and rescue services to establish what additional …
Accepted
In progress
P2-39 — Establish water undertaker communication protocols
Recommendation: That all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes. (113.63)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC and fire service lead officers for water are discussing with water undertakers how to strengthen existing arrangements …
Accepted
Delivered
JB-15.17 — Police medic training on catastrophic haemorrhage
Recommendation: Police medic training should emphasise that, in cases of catastrophic external torso haemorrhage, the immediate action is to apply direct pressure and then progress directly to using haemostatic gauze. Chest seals should only be used where there is no evidence …
Gov response: MPS formally responded on 28 October 2022 (paras 32-34). Senior First Aid Advisor Sue Warner reviewed training September 2021; confirmed no gap. Specific scenario on upper chest/neck catastrophic bleed now included in training.
Accepted
Delivered
JB-15.26 — Alternative to life hammer for window entry during armed operations
Recommendation: Consideration should be given by the MPS, Home Office and the NPCC to finding a more suitable solution for smashing windows during the course of an armed operation, so that an officer who is holding a firearm does not need …
Gov response: MPS formally responded on 28 October 2022 (para 39). MPS firearms no longer use glass hammer. Each officer issued extendable X-ball device; each team issued longer device for use at distance.
Accepted
No update 2+ yrs
LADB-13 — Endorse adoption of defensive driving teaching and practice by TOCs
Recommendation: The adoption by TOCs of the teaching and practice of defensive driving is endorsed (para 9.39).
Unknown
LADB-38 — Provide signallers with emergency stop options and regular situational briefings on use
Recommendation: The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options …
Unknown
LADB-41 — Utilise simulators for effective signaller training in emergency situations
Recommendation: The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).
Unknown
LADB-82 — Test integrating emergency hammers into passenger alarm system for controlled release.
Recommendation: Tests should be carried out into the practicability of building emergency hammers into the passenger alarm system so that they could be released only after an alarm has been activated (para 14.50).
Unknown
LADB-88 — Ensure unrestricted availability of all standard emergency equipment on passenger trains.
Recommendation: The availability on trains carrying passengers of the items of emergency equipment mentioned in the standard on emergency and safety equipment should be unrestricted (para 14.74).
Unknown
MAI-116 — Consider freeze-dried plasma for HART operatives
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider whether all Hazardous Area Response Team operatives should be deployed with freeze-dried plasma and trained in …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-153 — Use recording equipment during exercises
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that, in the course of exercises, such equipment is used by those who would use it in the circumstances of a …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-154 — Training on use of recording equipment
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that training is given to all who are issued with such equipment, on the circumstances in which it should be used …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-165 — Ten Second Triage training for frontline staff
Recommendation: The team led by Philip Cowburn has devised a tool that is designed for use by a wide range of emergency responders in a mass casualty situation. It is known as Ten Second Triage. The National Ambulance Resilience Unit, the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-49 — Review analgesia rollout to HART operatives
Recommendation: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other …
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
MAI-91 — Review analgesia deployment for firearms officers
Recommendation: The College of Policing and Counter Terrorism Policing Headquarters should review whether firearms officers should be deployed with analgesia and trained in its use, as part of providing Care Under Fire.
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
POPP-A.3 — Home Office to develop more suitable personal radios for police
Recommendation: Early attention should be given by the Home Office Directorate of Telecommunications to consider the practicality of producing a more suitable personal radio for the police.
Unknown
TAYL-F21 — Provide trained personnel and cutting equipment for immediate perimeter fence removal
Recommendation: Suitable and sufficient cutting equipment should be provided by the club at each ground where there are perimeter fences to permit the immediate removal of enough fencing to release numbers of spectators if necessary. Agreement should be reached as to …
Unknown
TAYL-I39 — Require clubs to provide one trained first aider per 1,000 spectators
Recommendation: There should be at each stadium at each match at least one trained first aider per 1,000 spectators. The club should have the responsibility for securing such attendance.
Unknown
TAYL-I40 — Local authorities to specify first aid rooms and equipment for stadium safety certificates
Recommendation: There should be at each stadium one or more first aid rooms. The number of such rooms and the equipment to be maintained within them should be specified by the local authority after taking professional medical advice and should be …
Unknown
TAYL-I41 — Require clubs to employ trained medical practitioners at all matches
Recommendation: The club should employ a medical practitioner to be present at each match and available to deal with any medical exigency at the ground. He should be trained and competent in advanced first aid. He should be present at the …
Unknown
TAYL-I42 — Mandate one fully equipped ambulance at matches with over 5,000 spectators
Recommendation: At least one fully equipped ambulance from the appropriate ambulance authority should be in attendance at all matches with an expected crowd of 5,000 or more.
Unknown
TAYL-I43 — Local authorities to specify ambulance numbers for large crowd matches
Recommendation: The number of ambulances to be in attendance for matches where larger crowds are expected should be specified by the local authority after consultation with the ambulance service and should be made a requirement of the Safety Certificate.
Unknown
AG-3 — Code of Practice on New Weapons Approval
Recommendation: The Home Secretary should ensure that the new Code of Practice on Police use of Firearms and Less Lethal Weapons contains an express prohibition on the use of a new weapon system by the police service until the approval process …
Gov response: 16. The Government accepts this recommendation. On 14 January 2020, the Home Secretary approved the revised Code of Practice for Armed Policing and Less Lethal Weapons (LLW). The Code has now been published on The …
Accepted
Delivered
AG-4 — North West Armed Policing SOP Amendment
Recommendation: The North West Armed Policing Standard Operating Procedure on Weapons and Ammunition should be amended so that it only permits the use of new specialist munitions that have been approved in accordance with the Code of Practice for Armed Policing …
Gov response: 20. The use of CS dispersal canisters by GMP during Operation Shire was a focus of concern for the Inquiry. The CS dispersal canisters had not been through the approval process that includes the identification …
Accepted
Delivered
AG-7 — Recording of Firearms Operations
Recommendation: During post incident proceedings following a police shooting, NPCC should consider the advantages of: Recordings of the communications of firearms commanders and authorised firearms officers (AFOs); And video recordings from the body-worn video cameras of AFOs and police vehicles involved …
Gov response: 31. The Government understands that body worn video (BWV) is now a requirement for all Armed Response Vehicle officers. Specialist Firearms Officers use BWV when deployed overtly. NPCC have issued guidance to encourage the use …
Accepted
No update 2+ yrs
AG-9 — Maximum Continuous Duty Period for AFOs
Recommendation: The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether there should be a maximum period of time during which authorised firearms officers (AFOs) are permitted to remain …
Gov response: 37. Following discussions with NPCC and the College of Policing, the Government understands that current guidance does not specify a time limit and that there would be significant operational implications of doing so. There are, …
Accepted
No update 2+ yrs
COVID-M1.8 — Triennial Parliamentary Resilience Reports
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience. The reports should include as a minimum: the …
Gov response: No formal response published by this government.
Accepted in Part
In progress
COVID-M2.7 — Statutory Child Rights Impact Assessments
Recommendation: The UK government should introduce legislation to place child rights impact assessments on a statutory footing in England. The Northern Ireland Executive should consider an equivalent provision.
Gov response: No government response yet received. Module 2 report published 20 November 2025.
Response Unclear
COVID-M3.3 — Fit-Testing Preparedness
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability …
Gov response: No formal response published by this government.
Unknown
PFD Reports (106) — showing 100 most recent
Chloe Ulett
Concerns: There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, especially for postpartum women.
Pending
Haaris Bhatti
Concerns: Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Response: FOLD nightclub has reviewed and revised its welfare escalation procedures to ensure earlier ambulance calls for seriously unwell guests. They have also introduced enhanced monitoring, updated public awareness communications, and …
Responded
Jean Groves
Concerns: Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Response: Norfolk County Council is issuing a communication to all Operational Managers and Reablement Liaison Officers to remind staff that every referral, whether accepted or declined, must be recorded on the …
Overdue
Suzanne Pemberton
Concerns: The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.
Response: East Suffolk and North Essex NHS Foundation Trust has undertaken a project to ensure all relevant ward areas receive consistent training related to dietetic care planning. They are also carrying …
Responded
Adam Hussain
Concerns: The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.
Response: NHS England acknowledges the concerns and notes that a system-wide After-Action Review has been facilitated by the Integrated Care Board, with outcomes to be monitored by various governance bodies. They …
Response: East Midlands Ambulance Service has implemented several changes, including deploying senior clinicians in their Clinical Hub, ensuring clinicians review all information before transferring calls, and ceasing manual ITK push transfers …
Response: NEMS has ceased manually pushed calls, updated its Clinical Triage Guideline, introduced daily reviews of Category 3 calls, and established a Clinical Triage working group. They are also developing a …
Response: The ICB facilitated a system-wide After-Action Review, ceased some automatic call transfers to NEMS, reviewed and redefined the Urgent Care Clinical Hub service specification, and developed new analytics capabilities for …
Responded
Connor Nelson
Concerns: Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its investigation and referral.
Response: Sherwood Forest Hospitals NHS Foundation Trust has conducted cardiac arrest simulation sessions and provided defibrillation training for EAU medical staff, introducing new mandatory annual BLS/ALS training. They also developed and …
Responded
Jamie Funnell
Concerns: An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Response: Practice Plus Group has implemented bimonthly dip tests for emergency response bags, delivered comprehensive training, and implemented a new guidance document. They also confirm that the alcohol dependence policy was …
Responded
Mark Townsend
Concerns: Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Response: Sheffield Wednesday Football Club disputes that the brief delay in radio communication indicates an unsafe system, noting the inquest found no causative failings. They state they will continue existing measures …
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
Ann Laskowsky
Concerns: Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Response: The College of Policing revised its First Aid Learning Programme (FALP) in 2023, expanding content and training time to include advanced casualty assessment and recognition of acute alcohol intoxication, now …
Response: West Yorkshire Police has updated its operational briefings and guidance to reinforce the use of the YAS Partner Triage Line, and has tasked a team with monitoring its usage. They …
Response: The NPCC confirms a full review of the Police First Aid Learning Programme (FALP) was conducted in 2023 and implemented this year, mandating assessment of breathing and responsiveness. They have …
Responded
Zara Cheesman
Concerns: Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.
Overdue
Mohammed Khan
Concerns: Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a critical birth.
Responded
Stuart Gilchrist
Concerns: Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
Overdue
Emily Stokes
Concerns: Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for seriously unwell individuals.
Responded
Oladeji Omishore
Concerns: Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental health state during interaction.
Overdue
Eleanor Curley-Bennett
Concerns: There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.
Responded
Jason Holland
Concerns: Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
Responded
Harry Dunn
Concerns: Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide timely pain relief and potentially delaying life-saving pre-hospital treatment.
Overdue
Kevin Cashin
Concerns: Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum is insufficient in these critical areas.
Responded
Stefan Walker
Concerns: Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.
Responded
Ben Harrison
Concerns: Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure medical emergencies.
Responded
Ronald Jepson
Concerns: Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Pending
David Siirak
Concerns: Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Responded
Severine Kelly
Concerns: Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.
Responded
Samuel Curless
Concerns: Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Responded
Peter Stajic
Concerns: Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical nature in specialist vascular knowledge.
Responded
William Gray
Concerns: Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.
Responded
Luca Yates
Concerns: Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal resuscitation.
Responded
Chantelle Reed
Concerns: Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Responded
Marcel Wochna
Concerns: Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.
Responded
Lamont Roper
Concerns: Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
Responded
Leonard King
Concerns: Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due to a perception it's a childhood disease. Education is needed for timely recognition.
Overdue
Andrew Vizard
Concerns: Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Overdue
[REDACTED]
Concerns: Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers during a critical incident.
Responded
Jodie McCann
Concerns: Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.
Responded
David Mason
Concerns: Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust guidelines and documentation lacked crucial prompts for adrenal insufficiency.
Responded
Angela Kearn
Concerns: Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient public warnings regarding risks for users with cardiovascular/respiratory conditions.
Overdue
Samantha Boazman
Concerns: Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with recording forms.
Responded
Arthur Trott
Concerns: Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of consultant midwives providing obstetric support across ambulance services.
Overdue
David Honnor
Concerns: Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency identification, and safety information on labels is insufficient.
Overdue
Raphael Gill
Concerns: Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.
Responded
Alfie Stone
Concerns: Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
Responded
Richard Sanders
Concerns: There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.
Responded
Jonathan Bayliss
Concerns: Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.
Responded
Louie Johnston
Concerns: CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training compliance.
Overdue
Leon Briggs
Concerns: The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Responded
Chimezie Daniels
Concerns: CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.
Responded
Nadeem Ahmed
Concerns: Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially due to a lack of shared training or checklists between paramedics.
Responded
Mohammed Zeb
Concerns: A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene hindered efforts to save a non-swimmer.
Overdue
Lynn Hadley
Concerns: 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.
Responded
Sharon Kelly
Concerns: 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.
Overdue
Richard King
Concerns: 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.
Overdue
Jake Lee
Concerns: The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.
Overdue
Zachary Johnson
Concerns: Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.
Overdue
Thomas Browne
Concerns: Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.
Overdue
Cesar Gonzalez Barron
Concerns: Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic scene that delayed CPR and ambulance access.
Overdue
Jonathan Ball
Concerns: The HGV lacked warning devices, its driver was untrained to report hazards, and ineffective rear hazard lights made the stranded vehicle dangerously inconspicuous, increasing collision risk.
Responded
William Vickers
Concerns: Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified paramedic, impacting effective communication and care.
Responded
Annabel Newport
Concerns: Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system that allows drivers to prematurely terminate communication were significant safety concerns.
Overdue
Edir DA Costa
Concerns: Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Responded
David Dooley
Concerns: Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.
Responded
Wayne Rodgers
Concerns: Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
Responded
Mark Kubiak
Concerns: The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.
Overdue
Christopher Moss
Concerns: Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.
Overdue
Jeremy Sutch
Concerns: Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a risk for future survivable injuries.
Overdue
Jack Riding
Concerns: There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.
Overdue
Suleyman Yalcin
Concerns: Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Responded
Charles Rashan
Concerns: Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.
Responded
Bryan Allsop
Concerns: Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.
Overdue
George French-Russell
Concerns: Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.
Overdue
Darren Powney
Concerns: Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.
Responded
Russell Sherwood
Concerns: The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.
Responded
Najeeb Katende
Concerns: There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.
Overdue
Ajvir Sandhu
Concerns: Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific light aircraft types for pilots.
Overdue
Rex Hall
Concerns: Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.
Responded
Rosemarie Dees
Concerns: An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.
Overdue
Sydney Neil
Concerns: After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Responded
Stephen Hunt
Concerns: Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Responded
Christopher Sears
Concerns: Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Responded
Mia Gibson
Concerns: Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.
Overdue
Carl Thompson
Concerns: Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training and information provided to holidaymakers.
Overdue
Doreen Mattinson
Concerns: Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.
Overdue
Philmore Mills
Concerns: Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
Overdue
James Barrett
Concerns: Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for searchers.
Responded
Eitvydas Zdanys
Concerns: Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
Responded
Steven Jackson
Concerns: A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Overdue
Stephen O’Malley
Concerns: Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.
Responded
Barbara Harrison
Concerns: Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
Overdue
Cameron Laing
Concerns: Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.
Responded
Grant Benson and Gordon Davidson
Concerns: Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented effective call transfer or dispatch of a nearby ambulance, causing critical delays.
Pending
Anthony Offord
Concerns: Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.
Overdue
Richard Barker, Ryan Bramwell and Robert Graham
Concerns: Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police officers were unaware of their statutory power to close roads for safety reasons.
Overdue
Hywel Hughes
Concerns: Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Overdue
Joanne Oliver
Concerns: A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.
Overdue
Desiree Falvo
Concerns: A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
Responded
Stephen Bedford
Concerns: Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Overdue
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Responded
Christopher Williams
Concerns: A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Overdue
Paul Rogerson
Concerns: River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.
Overdue
Albert James Hand
Concerns: Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, and current emergency call protocols are putting patients at risk.
Response: The Trust has reviewed and implemented an updated Demand Management Plan, recruited 100 new frontline clinicians, and commenced issuing a clinical manual. They are also commissioning an upgrade to their …
Responded