Rigid MPDS questioning leads to under‑prioritisation of unconscious patients
London Ambulance Service NHS Trust received 3 coroners' reports about this hazard between 27 May 2015 and 8 Jul 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“When [the deceased]'s mother replied "no", the EMD went on to ask "Is he conscious?”
Original on judiciary.uk ↗ London Ambulance Service NHS Trust responded.Response (PDF) ↗
- 3 years 3 months laterClosely relatedConfidence 0.80 · moderate
“A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.”
Original on judiciary.uk ↗ No published response from London Ambulance Service NHS Trust was found for this report.
- 6 years 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr [name redacted] during the first 999 call, namely that he thought and felt like he was having a heart attack.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to London 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.
2015 → 2018David Sweeney3 years 3 months after Yusuf Abdismad · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems in how emergency medical dispatchers assess whether a patient is conscious or unconscious, leading to incorrect assumptions. The later report shows the same issue persisting, affecting call prioritisation.
Yusuf Abdismad · 27 May 2015
“When [the deceased]'s mother replied "no", the EMD went on to ask "Is he conscious?”
Original on judiciary.uk ↗ David Sweeney · 19 Aug 2018
“A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.”
Original on judiciary.uk ↗ 2018 → 2025Miles Robinson6 years 11 months after David Sweeney · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that the MPDS triage system's rigid questioning fails to capture critical patient information, leading to under‑prioritisation of emergency calls.
David Sweeney · 19 Aug 2018
“A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.”
Original on judiciary.uk ↗ Miles Robinson · 8 Jul 2025
“Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr [name redacted] during the first 999 call, namely that he thought and felt like he was having a heart attack.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No published response from London Ambulance Service NHS Trust was found for this report.
No published response from London Ambulance Service NHS 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 London 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 |
|---|---|---|---|---|
| 2015 → 2018 | 0.68 | 0.06 | Closely related · 0.80 | same |
| 2018 → 2025 | 0.69 | 0.06 | Closely related · 0.85 | different |
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.