Lack of clear protocol for repeated 999 calls and non-ambulance response
North East Ambulance Service NHS Foundation Trust received 2 coroners' reports about this hazard between 10 Nov 2017 and 6 Dec 2019.
They came from 2 different coroners in 2 coroner areas. 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers can unintentionally build a picture about an individual.”
Original on judiciary.uk ↗ North East Ambulance Service NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust will address each point you have raised in your matters of concern below.”
- 2 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to North East Ambulance Service NHS Foundation 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.
2017 → 2019Maureen Wharton2 years 1 month after Darren Powney · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the absence of a clear NEAS protocol or guidance for ambulance staff beyond basic ambulance allocation.
Darren Powney · 10 Nov 2017
“It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers can unintentionally build a picture about an individual.”
Original on judiciary.uk ↗ Maureen Wharton · 6 Dec 2019
“c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation”
Original on judiciary.uk ↗
Stated action
“The Trust will address each point you have raised in your matters of concern below.”
No published response from North East Ambulance Service NHS Foundation Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 North East Ambulance Service NHS Foundation 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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.65 | 0.04 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for North East Ambulance Service NHS Foundation Trust
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.