Brian Ingram

Suite 6, Carew House 
Beacon Technology Park 
Dunmere Road 
Bodmin 
Cornwall 
PL31 2QN 

HM Senior Coroner Mr Andrew Cox 

29 January 2026 

Dear Mr Cox  

Thank you for your letter and report dated 8 October 2025.   

We  are  grateful  for  the  opportunity  to  address  your  concerns,  which  have  arisen 
concerning  Mr  Ingram’s  care.  A  meeting  of  all  recipients  of  your  report  took  place 
following  the  inquest.  The  following represents the  joint  response  of  Cornwall 
Western Ambulance 
Partnership 
Service Foundation Trust  (SWAST)  and Lifestar Medical  Limited  (LML).  All  parties 
wish to express their sincere condolences to Mr Ingram’s family for their loss. 

(CFT), South 

Foundation 

Trust 

Your  letter  sets  out  seven  areas  of  concern,  upon  which the parties  have  had  the 
opportunity  to  reflect individually  and  collectively, following  the  inquest.  We  have 
summarised below; the  issues  you  have  asked  the  parties  to consider  and address 
and have responded to each in turn.   

1.  The  importance  of  proper  introductions  between  ambulance  crews  and 
family  members,  to  include  confirmation  of  a  staff  member’s  clinical 
grade.  

1.1 Since  the  inquest,  LML  has  issued  an  organisation-wide  memorandum 
concerning the mandatory requirement for all staff to clearly identify themselves 
to  all  patients, families and  partner  agencies.  This  information  must  include 

To contact us, call the number at the top of this letter  
Visit our website: cornwallft.nhs.uk 

Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN.  
Telephone: 01208 834 600. Matthew Taylor, Chair. Debbie Richards, Chief Executive.  

 
 
 
 
  
  
 
 
 
  
  
  
  
  
 their first name and clinical role, for example, for an Emergency Care Assistant 
(ECA), what this entails and its distinction from the role of a paramedic. The 
scope of their practice must also be clarified and outlined at the beginning of 
every patient encounter and during interactions with other organisations. The 
memorandum issued to staff includes practical examples of how each role, and 
its limitations, should be explained. Staff have also been reminded of the strict 
requirement  to  adhere  to  uniform  policy,  which  includes  always  wearing  the 
correct epaulettes.   

1.2 LML  delivers  three  mandatory,  annual  face-to-face  training  days  for  staff,  to 
ensure their competence and alignment to organisational standards. On each 
day of this training, the importance of clear introductions is reiterated to staff, 
and put in practice through group discussions and acting out scenarios.    

2.  The practice of asking a family member to remain in the ambulance while 

Mr Ingram was clerked in.   

2.1 All  parties  recognise  the  importance  of  involving  and  consulting  with  family 
members  or  carers,  when  assessing  a  patient  and  taking  their  history.  As 
you identified,  had  Mr  Ingram’s  daughter  been  with  him  when  he  was  taken 
into Camborne  &  Redruth  Community  Hospital Minor Injuries  Unit  (MIU), she 
may have been able to provide additional information or context concerning his 
injury, including the fact that he was experiencing groin pain. This in turn may 
have prompted further investigation of Mr Ingram’s injury and/or escalation to 
the acute hospital (Royal Cornwall Hospital Emergency Department (ED)). The 
involvement of family members in Mr Ingram’s case was of greater importance 
due  to  his  dementia,  and  the  impact  this  had  on  his  ability  to  provide an 
accurate history to the ambulance crew or clinician.  

2.2 It was suggested in evidence at the inquest, that the practice of asking a family 
member to remain in the ambulance, may have been a remnant of procedure 
adopted during the COVID-19 pandemic. LML has reflected upon the decision 
of the ECA ambulance crew in this case, which was not in line with their policy. 
Following the inquest, LML has:   

2.2.1  Issued an organisation-wide memorandum to remind all staff:   

a.  Of  the important  role that  patients’  relatives  and  carers  play  in 

supporting safe and effective patient care.    

b.  Of the mandatory requirement to ensure that relatives and/or carers 
are not excluded from any stage of the assessment or care process. 
The only exception to this is where a patient with capacity, declines 

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 to  be  accompanied  by  or  share  information  with  a  person,  and/or 
where there is a clear safety issue or safeguarding concern.   

c.  That  the presence  of  relatives/carers  is  often  vital  to  obtain an 
accurate history,  to  understand  the  patient’s  ‘baseline’  and  to 
recognise subtle changes or nuances that the patient may not be able 
to  express  themselves.  This  is  especially  important  when  patients 
lack  capacity  in  relation  to  their  care  and  treatment,  have  memory 
impairment,  cognitive difficulties or  communication  challenges. 
Relatives and carers often hold key information that supports clinical 
decision-making and safeguards the patient’s best interests.   

d.  Where any concerns arise about a relative’s presence, the decision 
to  exclude  them  must  be  clearly  justified,  documented  and 
proportionate, with the patient’s safety and wellbeing as the primary 
consideration.   

2.3 Whilst  CFT  was  not  aware  that  Mr  Ingram’s  daughter  was  waiting  in  the 
ambulance in this case, we appreciate that had our Minor Injuries Unit (MIU) 
staff  come  to  the ambulance  to  carry out  an  initial assessment  of Mr Ingram 
and consider his suitability for review and/or treatment in the MIU, they would 
have discovered her waiting there, and had the opportunity to take any relevant 
history.  It is established MIU practice to assess patients in the ambulance, prior 
to  checking  them  in.  This  is  expressly stated in  the  MIU  Operational  Policy, 
which  sets  out  the  procedure  for  patients  being  brought  into  the  MIU  by 
ambulance, as follows:   

“In the event of a patient arriving by ambulance it is the responsibility of the MIU 
to  assess  the  patient  in  the  ambulance  with  the  paramedics  prior  to 
offloading.  If  the  patient  has  a  minor  injury  /  illness,  which  is  suitable  for 
treatment within guidelines, and there is every expectation that the patient will 
be discharged independently from the MIU directly home, the Practitioner will 
accept  the  patient  from  the  ambulance  crew.  This  process  is  supported  by 
Southwestern Ambulance Service Foundation Trust. A copy of the ambulance 
documentation must accompany the patient and be left with the MIU receiving 
team.”   

2.4 Assessing  the  patient  in  the  ambulance  enables  the  assessing  practitioner 
to establish whether the MIU is the correct setting for their treatment, or whether 
they  require  assessment  and  care  by  clinicians  working  in  an  emergency 
department (ED), for example. It has become clear following the inquest, that 
LML (who do not routinely transport patients to the MIU), were not familiar with 
this  procedure.  Learning  has  been  discussed  between  the  parties, and  the 

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 Operational Policy has been shared by CFT with LML, to ensure that its crews 
are made aware of this.   

2.5 The facts relating to Mr Ingram’s inquest have also been used as a case study 
and  presented  at  the Learning  from  Experience  (LFE) Forum,  a  meeting 
attended  by  all  MIU  clinical  leads,  to  discuss  any  collective  issues  to  be 
addressed,  and  to  share  learning  and  best  practice  across  CFT.  It  was 
reiterated at the LFE Forum, that in accordance with policy, all patient arrivals 
via  ambulance  should  be  initially  assessed  in  the  ambulance,  and  a full 
assessment of the patient should be carried out by an MIU clinician (discussed 
further below).   

2.6 There  has  been  a  team-wide  communication  to  all  MIU staff,  reiterating  the 
requirement for all patients arriving by ambulance (SWAST or otherwise), to be 
physically  assessed  and  have  a  handover and history  taken  in  the  back  of 
the ambulance, before the patient is accepted into the MIU. It has been clarified 
that  the  patient  should  only  be  booked  in  to  the  MIU,  once  the  clinician  has 
confirmed  their  acceptance  with  the  admin  team.  Patients  arriving  by 
ambulance are not to be booked in until they have been assessed as suitable 
for treatment at the MIU.   

2.7 Teams have also been reminded to trust their clinical judgement when a patient 
arrives, and not to be afraid to decline a patient based on their own assessment 
if they do not feel the patient is appropriate for the MIU. This is expanded upon 
below.   

2.8 Key  themes and  learning arising  from  the  inquest,  have  also  been  shared 
with the service’s Clinical Quality and Governance Group (CQaGG), attended 
by  service  leads, and  other  patient  safety-related  forums.  These  include 
reminding MIU staff that ambulance patients must be assessed in the vehicle 
to establish whether  the  MIU  is  the  appropriate setting  and ensuring  that  the 
patient  record  is  shared  with  the  MIU  before  ambulance  crews  leave.  The 
importance  of  input  from  patients’  relatives  and  carers  has  also  been 
highlighted  with  teams,  to  ensure in  particular  that patients  with  dementia  or 
learning needs are accompanied. CFT’s Standard Operating Procedure for our 
Specialist  Dementia  Care  inpatient  ward,  reminds  staff  of  the  importance  of 
person-centred care, which includes allowing patients’ families and carers to be 
actively involved and consulted throughout. These principles apply throughout 
all care settings. All MIU and Urgent Treatment Centre (UTC) teams have been 
reminded  of  and  directed  to  this  policy, which has  formed  part  of  several 
LFE forums, shared with all relevant staff.     

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 3.  The  sharing  of 

information  between  different  organisations 
when transferring a patient to a new care setting. In this case, the concern 
related to discrepancies around the provision of the Patient Care Record 
(PCR) by the ambulance crew to the MIU.   

3.1 It  will ordinarily  be  a  SWAST  ambulance  that  attends  the  MIU with  patients. 
There is an established process whereby SWAST is able to send details of the 
incoming patient and medical history electronically. The usual process followed 
by ambulance crews when 
the  MIU has 
transferring 
been summarised by SWAST as follows:   

patients 

to 

3.1.1  Crews  will usually ring  ahead  prior  to  arriving  at  the  door  of  a  MIU  or 

UTC.   

3.1.2  Once  the crew  has arrived with  the  patient,  a  Healthcare  Professional 
(HCP)  will come  out  to  the  ambulance  to  see  the  patient,  physically 
assess their suitability for treatment at the MIU or UTC, and receive the 
verbal handover. The MIU Operational Policy on receiving patients from 
ambulance crews has been sent to SWAST as a reminder that patients 
are not to be brought in to the unit before being assessed for suitability.   

3.1.3  If  the  receiving  HCP  is  happy  to  accept  the  patient, then  the  crew 
will assist the  patient  into  the  department.  The  electronic PCR  is  then 
emailed  over 
is  undertaken  via 
the  MIU/UTC.  This  email 
the ‘MobiMed’  (a  mobile  app containing an  electronic  patient  record 
management  system), from  a  list of possible  email addresses  that are 
easy to select.   

to 

3.2 In  Mr  Ingram’s  case,  the ambulance which attended the  call  was  a  private 
ambulance  provided  by  LML, whose  staff  work  from  written  Patient  Clinical 
Records (PCR). The possibility of LML adopting a similar electronic system of 
the  associated  set-up  and 
recording  PCRs  was  discussed,  however 
maintenance costs were not considered financially viable for a medium sized 
ambulance provider. There was a conflict in the evidence at the inquest as to 
whether  a  PCR  was  provided  to  MIU  staff. During  discussions  between  the 
parties following the inquest, it was considered that the ECAs who brought Mr 
Ingram  into  the  MIU  may  have retained his  PCR,  rather  than  left  it  with  the 
MIU, because they were intending to wait for him to be x-rayed and then take 
him back home.   

3.3 LML  has  issued  a  company-wide  communication  to  all  staff,  to  ensure 
that appropriate handover of PCRs takes place. Staff have been reminded of 
their legal and professional duty to ensure that documentation is completed for 
is 
every  patient 

journey,  without  exception.  Accurate  documentation 

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 fundamental to safe, high-quality care and provides an essential audit trail for 
all clinical activity.   

3.4 LML  has also implemented  a  policy  which  applies  to  all  cases  where  crews 
transport  a  patient  to an alternative provider  (i.e. the  MIU  instead of  the  ED) 
and all parties agree that the same crew will transport the patient back to their 
point  of  origin. This  is  in  recognition  of  two  distinct  episodes  of  care,  each 
requiring  independent  clinical  documentation. In  these  circumstances, two 
separate  PCRs  must  be  completed.  A  full  PCR  is  to  be  completed  for 
the initial journey to the MIU, with a signed carbon copy to be left with the MIU. 
Another separate PCR is to be completed for the return journey and again, a 
carbon copy left with the patient when they arrive home and the crew departs.   

3.5 LML crews have also been reminded to ensure that PCRs are shared with the 
receiving destination in a timely manner and used alongside a structured verbal 
handover at every transfer of care. Documentation should never replace verbal 
communication; both are essential for continuity, safety, and clarity.  This has 
been codified in a new policy, which has communicated to staff and reinforced 
by: 

3.5.1  Emailing to individuals directly.  
3.5.2  Uploading  to  the  electronic  staff  record  system,  which  requires  staff 

acknowledgement to confirm that it has been read.  

3.5.3  Including this in staff training days; and  
3.5.4  Continuing LML’s practice of a monthly audit of PCRs, in which 10% of 
all  PCRs  are  reviewed  by  experienced  clinical  consultants,  against 
national  standards.  Any  sub-standard  practice  in  completing/sharing 
PCRs is addressed with the relevant staff member(s), with any repeat 
issues  generating  a  review  at  a  clinical  governance  meeting  and 
disciplinary procedures, where appropriate.  

3.6 As stated above,  most  ambulance  transfers  will  be  via  SWAST  ambulances 
and the  process  set  out  above  will  ensure  that timely transfer of patient  data 
takes place. LML has implemented policies and procedures to ensure that its 
own records are handed over to the HCP and patient for each episode of care. 
We recognise that there may however be ambulance calls attended by other 
private providers. In this case, Mr Ingram’s call was responded to by NHS 111, 
when  it  was allocated to  them  by  SWAST. It  was  clarified  by  SWAST  during 
discussions following the inquest, that SWAST categorised the initial 999 call 
from Mr Ingram’s family, and passed it to NHS 111 for further clinical input. At 
that point, the call was closed to SWAST.   

3.7 LML was therefore instructed by NHS 111 to attend to Mr Ingram. On the basis 
that future  calls could be  categorised  and  dealt  with  by  NHS  111  rather than 

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 SWAST, the parties considered it prudent (with your consent) to inform Kernow 
Health  CIC  (KHCIC)  (which  delivers the NHS  111 integrated  care  service) of 
this Regulation 28 Report. This was done with a view to ensuring that learning 
is  disseminated  to all  other  relevant  parties,  including  any  other  private 
ambulance firms who may be instructed to respond to such calls. The response 
from KHCIC is set out at paragraphs 5.1-5.2 below.   

is  booked 

3.8 From the perspective of CFT, all MIU staff have been reminded that the PCR, 
whether this is in paper form or any electronic PCR, should be received from 
in. Learning  has 
the  patient 
the  ambulance  crew  before 
been identified following the inquest in relation to patient handover at the MIU. 
It is acknowledged by CFT that there was an over-reliance on a verbal handover 
from the ambulance crew (believed by MIU staff to be paramedics), which had 
an impact on the initial assessment by the MIU practitioner. All staff have been 
reminded  of  the  importance  of  taking  a  full  patient  history  and  all  available 
patient  documentation,  prior  to  accepting  the  patient  on  to  the  MIU.  This 
via email 
learning and required actions  have been 
and have featured on  the  agenda  of MIU staff meetings over  the  last  12 
months.   

shared  with 

staff 

4.  Mr Ingram was seen by a triage nurse who ordered a knee x-ray only.   

4.1 A  number  of  contributory  factors  led  to  this  outcome,  including  the  lack  of  a 
PCR  and  any  detailed  handover  concerning Mr  Ingram’s  symptoms  and 
medical history; Mr Ingram’s own inability to give a full and accurate history; his 
family  waiting  in  the  ambulance  on  the  crew’s  instruction  and  therefore  not 
being  with him  when he  was  being  triaged; and  the  lack  of  any  full,  physical 
examination.   

4.2 Had the MIU procedure been followed as regards the examination of patients 
in  the  ambulance  prior  to  booking  them  in,  and  ensuring  handover  by 
ambulance crews of the PCR, then adequate clinical history should have been 
available from the PCR and/or Mr Ingram’s daughter. It is likely this would have 
resulted in Mr Ingram being transferred to the ED at Royal Cornwall Hospital for 
further examination and treatment.   

4.3 We have set out above, the measures taken by LML and CFT to ensure that 
MIU patient transfer protocols are followed, patient medical history is handed 
this 
over 
process. Additional learning  has  been identified in  relation  to  practitioners’ 
reliance  on previous assessments  of  patients.  This  is  detailed  further  in 
response to the concerns below.     

family  members 

promptly 

involved 

and 

are 

in 

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 5.  The  nurse  clinician  was  asked  to  review  the  x-ray  only.  There  did  not 
appear  to  have  been  any  check  as  to  whether  Brian  needed  to  be 
conveyed to RCH.   

5.1 Concerning  the  initial  decision  to  transfer  Mr  Ingram  to  the  MIU,  KHCIC  has 
reviewed your report and checked their records in relation to the role of NHS 
111 in Mr Ingram’s care. They have stated in response, that KHCIC provided 
no clinical assessment or judgement in this case. Their involvement was limited 
to  that  of  transport  dispatch  for  Mr  Ingram’s  conveyance  to  Royal  Cornwall 
Hospital ED, via LML. They acknowledge that the crew called NHS 111, and 
the decision was to convey Mr Ingram to the MIU instead.  

5.2 The dispatch function came under the umbrella of the Inter Facility Transport 
Contract (IFT). KHCIC’s function for this was a control and dispatch function for 
private ambulance services. KHCIC states that it acted as transport dispatch 
and did not otherwise manage Mr Ingram’s case and pathway options. The IFT 
contract  has  now  ceased  and  KHCIC  therefore  no  longer  dispatches 
ambulances under this system. 

5.3 As noted above, it is acknowledged that upon arriving at the MIU, Mr Ingram 
should  have  been  assessed  and  his  history  taken  in  the  ambulance, 
to identify whether the MIU was an appropriate setting for treatment. Had this 
been  done,  groin  pain  may  have  been  noted  from  the  PCR  and/or  from 
consulting with Mr Ingram’s daughter and may have prompted escalation of Mr 
Ingram’s  care  to  an  acute care setting.  One  of  the  reasons  this  was  not 
explored further by MIU staff, appears to have been an overreliance upon the 
assessment carried out by the LML ambulance crew, who were believed to be 
trained paramedics rather than ECAs (learning and actions identified in relation 
to this point are addressed further at paragraph 6 below).  

5.4 As patients are usually transferred to the MIU by SWAST ambulances, HCPs 
have  some  expectation  that  the  ‘Neck  of  Femur’  pathway  for  clinical  checks 
would be followed by ambulance crews. SWAST has outlined this process as 
follows:    

5.4.1  The ambulance crew attends an incident with a patient that has hip pain, 
suspecting a hip fracture, which they cannot completely rule out.   

5.4.2  The crew call the Single Point of Access and discuss this with either the 
acute GP or a clinician within KHCIC.  In Mr Ingram’s case, the ECAs 
from LML were dispatched at the instruction of NHS 111 (provided by 
KHCIC).   

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 5.4.3  If  it  is deemed necessary  for  the  patient  to  have  an  x-ray,  this  can  be 
arranged  by  the  crew  taking  the  patient  to  a  community  hospital  with 
Same Day Emergency Care (SDEC), which in this case, would include 
the MIU. Once there, the crew are requested to take the patient to the 
MIU for the x-ray and wait with the patient. If the x-ray comes back with 
a fracture showing, the crew would transfer the patient to the ED. If there 
is no fracture, then the crew can hand over the patient to the MIU and 
leave (although note that whilst this process applies to the MIU, it can 
vary slightly across different SDEC sites).  

5.5 CFT has also reflected on the missed opportunities to identify the extent of Mr 
Ingram’s injuries when he was brought into the MIU by the ambulance crew. 
Learning has been highlighted and communicated to all MIU teams concerning 
the importance of professional curiosity, both in terms of the information handed 
over by other HCPs, and the practitioner’s own assessment of the patient. The 
key  lessons  and  themes emerging following  the  inquest  have  been  captured 
and  discussed  at  MIU  meetings  and  on  a  wider  basis  across  CFT 
through CQaGG (as  described  above)  and  other  patient  safety  forums.  Staff 
have been reminded that the responsible clinician receiving the patient at the 
MIU is accountable for the entire period of patient care, which includes carrying 
out a full assessment of the patient in each case.   

6.  The nurse clinician at MIU did not know the ambulance staff were ECAs 
and had wrongly assumed they were paramedics and had conducted their 
own assessment  

an incorrect assumption 

6.1 As the majority of patients brought to the MIU arrive with SWAST ambulance 
crews, this led to 
were 
paramedics, and a  certain pathway  would  have  been  followed  as  regards  Mr 
Ingram’s assessment following a fall (details of which are set out at paragraph 
5.4  above). SWAST  sets  out  the  following  guidance  to  ambulance  crews 
on identifying themselves  (taken  from  their  ‘Accessing  Telephone  Advice’ 
policy):   

crew 

that 

the 

“6.5 Identifying your Clinical Grade   
6.5.1  When  seeking  advice,  staff  and  volunteers  must  inform  the  clinician  of 
their clinical grade. It is important that the clinician providing the advice is aware 
of  this,  as  their  advice  may  vary  between  an  ECA,  Technician,  and  a 
Paramedic.”  

There is an expectation that the crew communicate their role and grade to the 
HCP that is taking the handover.   

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 6.2 LML has taken steps to inform and train all its staff on the requirement to provide 
clear and consistent introductions to other HCPs. This includes an explanation 
of their role, any limitations in the service they can provide/the extent of their 
training, and the fact that they are not paramedics.   

6.3 As  highlighted  above,  CFT  has  also  reiterated  to  its  staff,  the  importance 
of each  clinician maintaining independent,  clinical  judgement when  carrying 
out  their  own  assessment  of  a  patient,  and  to  query/challenge  the  extent  of 
any previous assessment carried out, where necessary. This has taken place 
through the training and communications to all MIU staff described above, and 
the  wider  dissemination  of  learning  across  CFT,  through  its  quality  and 
governance, and patient safety forums.   

7.  The  nurse  clinician  did  not  conduct  his  own  physical  assessment  or 
speak to the available family member to confirm the relevant history and 
presenting complaints.   

7.1 We recognise that this was an important missed opportunity. CFT has taken 
clear and decisive steps to ensure that all staff are aware of the requirement to 
carry  out  a  full  physical  assessment  when  patients  are  brought  to  the  MIU 
(assuming  they  are  initially deemed to  be  suitable  following  an  ambulance-
based  triage).  This  has  been  communicated  in  MIU  team  meetings,  LFE 
Forums,  clinical  supervision  meetings,  and  across CQaGG and  other  patient 
safety  forums  attended  by  team  leads  across  the  spectrum  of  community 
services. CFT will continue to monitor the implementation of this learning, when 
carrying  out  documentation  audits  and  observations  of  care, as  part  of  our 
ASPIRE accreditation requirements.   

The concerns raised in your report have given all parties the opportunity to reflect on 
Mr Ingram’s care. The various connected factors described above, led to a series of 
missed opportunities to escalate his care to the correct setting in the ED.   

We  hope  that following  Mr Ingram’s sad death, this response provides some  insight 
into the detailed discussions which have taken place across all recipient organisations, 
to ensure that learning is embedded and reflected in daily practice, and that this offers 
some reassurance that your concerns have been addressed.   

Yours sincerely 

Chief Improvement Officer  

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 Cc: South Western Ambulance Service 
Lifestar Medical Limited 

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