Ambulance fails to document refusal consent
West Midlands Ambulance Service received 2 coroners' reports about this hazard between 18 Nov 2019 and 14 Dec 2020.
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.
“The paramedic asked the deceased's partner to sign the 'non-conveyance' statement on his EPR tablet after summarising a 1 hour 45 minute attendance.”
Original on judiciary.uk ↗ West Midlands Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“We are currently in the process of changing the software on our electronic patient report to include a statement that will be visible on the screen where patients, family or carers will see and read prior to signing. This statement clearly sets out that they are signing to acknowledge the refusal for treatment and/or transport to hospital and/or referral for further care against the advice of the attending ambulance clinicians. It also goes on to state that the risks of this has been explained”
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;”
Original on judiciary.uk ↗ Repeated from the earlier report:askedsign
West Midlands Ambulance Service responded.Response (PDF) ↗
- All reports to West Midlands Ambulance Service
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.
2019 → 2020Elsie Taylor1 year 1 month after Emma Langley · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that the ambulance service fails to properly document and convey a patient's or family's understanding when refusing hospital transport. The earlier case concerns an unclear signature on a tablet; the later case notes missing records of advice and no disclaimer signature.
Emma Langley · 18 Nov 2019
“The paramedic asked the deceased's partner to sign the 'non-conveyance' statement on his EPR tablet after summarising a 1 hour 45 minute attendance.”
Original on judiciary.uk ↗ Elsie Taylor · 14 Dec 2020
“(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are currently in the process of changing the software on our electronic patient report to include a statement that will be visible on the screen where patients, family or carers will see and read prior to signing. This statement clearly sets out that they are signing to acknowledge the refusal for treatment and/or transport to hospital and/or referral for further care against the advice of the attending ambulance clinicians. It also goes on to state that the risks of this has been explained”
Stated action
“We are currently in the process of changing the software on our electronic patient report to include a statement that will be visible on the screen where patients, family or carers will see and read prior to signing. This statement clearly sets out that they are signing to acknowledge the refusal for treatment and/or transport to hospital and/or referral for further care against the advice of the attending ambulance clinicians. It also goes on to state that the risks of this has been explained”
No specific action could be extracted with a verified quote.
- 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 West Midlands Ambulance Service 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 |
|---|---|---|---|---|
| 2019 → 2020 | 0.70 | 0.13 | Closely related · 0.90 | 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.