Inadequate dissemination of protocol changes to frontline staff
East Midlands Ambulance Service NHS Trust received 2 coroners' reports about this hazard between 9 Apr 2014 and 31 Jan 2017.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.”
Original on judiciary.uk ↗ East Midlands Ambulance Service NHS Trust responded.Response (PDF) ↗
- 2 years 10 months laterIdentical hazardConfidence 0.90 · high
“We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change.”
Original on judiciary.uk ↗ Repeated from the earlier report:staffread
East Midlands Ambulance Service NHS Trust responded, stating 4 specific actions.Response (PDF) ↗
“The revised version has been approved within EMAS and | have attached a copy for your reference.”
“The guidance from the document provides the following information around 'futility' and when decisions not to attempt CPR because it will not be successful may be made. The following section has been added to the procedure to provide additional guidance to clinicians”
2 more stated actions in the Promises tab.
- All reports to East Midlands Ambulance Service NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2017Dipa Lad2 years 10 months after Sally Perrons · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with communicating protocol changes to frontline staff and verifying that the information is received and understood.
Sally Perrons · 9 Apr 2014
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.”
Original on judiciary.uk ↗ Dipa Lad · 31 Jan 2017
“We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action
“The revised version has been approved within EMAS and | have attached a copy for your reference.”
Stated action
“The guidance from the document provides the following information around 'futility' and when decisions not to attempt CPR because it will not be successful may be made. The following section has been added to the procedure to provide additional guidance to clinicians”
Stated action
“We heard that EMAS relies on emailing changes in protocol to staff. There is no check that busy staff have read and understood these, and there has been no training on this change”
Stated action
“EMAS policy around diagnosis of death differs in a key respect from JRCALC guidelines - but there is no equivalent pocketbook/amending to existing pocketbook/similar which reflects local policies”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to East Midlands Ambulance Service NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2017 | 0.72 | 0.08 | Identical · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.