Delayed symptom recognition leading to missed emergency response
London Ambulance Service NHS Trust received 2 coroners' reports about this hazard between 12 Jun 2018 and 27 Apr 2022.
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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
Original on judiciary.uk ↗ London Ambulance Service NHS Trust responded, stating 3 specific actions.Response (PDF) ↗
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”
“During the afternoon of 29" January 2018 demand in the service was above that predicted and staffing levels both operationally and in the Clinical Hub were below the below the planned”
1 more stated action in the Promises tab.
- 3 years 10 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency”
Original on judiciary.uk ↗ London Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”
Stated timescale: early Autumn 2022
- 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.
2018 → 2022Raphael Gill3 years 10 months after Olive Nutt · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in recognizing critical symptoms during ambulance calls, leading to inappropriate prioritisation and delayed emergency response.
Olive Nutt · 12 Jun 2018
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
Original on judiciary.uk ↗ Raphael Gill · 27 Apr 2022
“It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”
Stated action
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”
Stated action
“During the afternoon of 29" January 2018 demand in the service was above that predicted and staffing levels both operationally and in the Clinical Hub were below the below the planned”
Stated action · timescale: September 2018
“The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester Triage System and with specific Clinical Hub training.”
Stated action · timescale: early Autumn 2022
“we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”
- 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 |
|---|---|---|---|---|
| 2018 → 2022 | 0.69 | 0.00 | Closely related · 0.80 | 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.