Derek Burt

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT 
FUTURE DEATHS 

Please do not include any living person names in this document, in accordance 
with the Chief Coroner’s publication policy PDF. 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner for the Coroner Area West Sussex, Brighton and Hove in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ 
following an investigation into the death of Derek Thomas BURT, and an inquest 
that concluded on 02 June 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, APPELLO CARELINE LTD provides this response within 
56 days of the date of the Report to Prevent Future Deaths or any extension 
granted. 

2. 

3. 

DATE OF RESPONSE: 3rd July 2026 

CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

The MATTERS OF CONCERN are as follows:  
Overall, I accept this was an unusual set of circumstances in that the call to 
emergency services was made by a careline operator who was relaying 
information from the patient’s wife who was herself the careline user and she 
was bedbound so not in a position to assist her husband who was bleeding 
heavily and non responsive, nor could she get to a phone to answer (as it 
was in another room) the numerous calls made by the EMA and ambulance 
clinical safety navigator.   

That said, no one appears to have thought that the Appello careline system 
could have been used to speak to Mrs Burt via a third party conference call 
as that is the very method used to call for help and she used it successfully, 
not once, but twice. I am concerned that this system and technology is 
utilised fully to potentially give vital clinical advice that may save future lives. 

1) I heard evidence from the call centre manager of Appello Careline and the 
first careline operator that their system has the capability to speak directly to 
Mrs Burt without her pressing her wrist alarm button as this could have been 
done via the digital base unit that was in her bedroom.  The system can also 
set up a 3 way conversation or conference call to include any of the 

 
 
 
 emergency services.  Indeed the operator told me she has done this in the 
past if asked to do so by the emergency services or she has suggested it but 
she did not do so in this case as she took her lead from the EMA.   

Conversely, I heard from a clinical safety navigator (CSN) with SECAMB that 
she did not know careline companies could set up 3 way conference calls for 
a CSN to speak to the patient or helper directly. She knew that Police and 
Fire Services used 3 way conference calls using careline systems but not 
Ambulance Trusts.  

This case had moved from the dispatch to the clinical stack and from the 
timeline of calls supplied it seems 15 calls were made between 22:52 and 
23:23 to the landline and mobile numbers supplied but of course, it was 
impossible for Mrs Burt to answer them.  No one thought to go back through 
the digital base unit to offer the basic clinical advice that was needed.  I am 
concerned that both Ambulance Trusts generally as well as Careline 
companies may not be aware of the potential to save lives using available 
technology. 

2) I also heard from the careline centre manager that Appello does not have 
any specific documentation, training material or guidance that considers calls 
for assistance made by the service user for people other than themselves.  It 
was good to learn that both careline operators did respond positively to the 
cry for help from Mrs Burt.  I remained concerned however that there is no 
policy or guidance available for operators to cover this type of emergency or 
life threatening situation and no training has yet been devised to learn from 
the unusual circumstances that occurred here. 

3) I also remain concerned that the first careline operator did not pass on a 
key piece of information to the EMA, namely that the caller did not have 
access to a phone.  Nor did she ask if the blood was spurting or dribbling.  
Although, it was relayed that Mrs Burt was bedbound, the EMA would not 
have realised that Mrs Burt couldn’t get to the phone as it was in another 
room.   

In addition the first careline operator did not call the EMA back when she 
learned Mr Burt was non responsive and had developed breathing problems.  
The CSN confirmed to me that if a second call had been made at that point 
then the call would have been upgraded to category 1.  This would have been 
at approx 22:50.  In other words around the same time the EMA was trying to 
call Mrs Burt back.  The clinical review was allocated at 22:55 and the second 
999 call was logged at 23:15 so approximately 20-25 mins had elapsed. 

4) Likewise I heard from the SECAMB CSN that she had carried out an audit 
of the EMA notes added to their system when speaking to the first careline 
operator. She did so from a clinical perspective and she discovered missing 
information that was given but not recorded at all namely: that there had 
already been 20 minutes of bleeding at the time of the first call (approx. 
22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was 
bedbound therefore could not assist Mr Burt. None of this information was 

 
 
 
 
 
 
 therefore available to the CSN who carried out the clinical review. 

 In addition I heard that the end to end review carried out by SECAMB and 
focused on the dispatch difficulties that existed on 14 May 2025. I appreciate 
that the dispatch and clinical review systems were different at that time and 
have now been changed but I remain concerned that the quality of note 
taking has not been properly checked and action taken to rectify then make 
improvements with any individual concerned as well as capturing learning 
points for others. Here vital information was missing and was needed to 
ensure an effective clinical review could take place and thereby ensure that 
the category of call response is accurate.  

I was told this call had been audited and was found to be 95% compliant. 
This also calls into question the quality of the call auditing system  

5) I heard that an EMA can hold a call and speak to a CSN to get basic first 
aid advice or join the CSN into the call. Given the volume of blood that had 
already been lost in this case, I am concerned that this opportunity to give 
clinical advice was lost especially as the call had come in via a careline 
operator.  

6) I was told that SECAMB is taking part in a pilot called Tortoise looking at 
using AI to improve the accuracy of note taking. It was unclear whether a 
similar scheme is being explored by careline companies or if there is effective 
liaison between careline companies and ambulance trusts. 

4. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 

Appello Careline Limited has carefully considered each of the matters of 
concern raised in the report and has reviewed the circumstances of this case 
in detail. 

The circumstances of this incident were unusual, involving a combination of 
factors including the service user being bedbound, the person requiring 
assistance not being the Appello customer, and the absence of accessible 
telephone contact within the property. 

Concern 1 
Appello Careline Limited’s existing triage processes require operators to 
gather and communicate relevant information to emergency services. Those 
processes remain in place and are considered appropriate to ensure that 
relevant information is identified and communicated to emergency services. 

Concern 2 
Appello Careline Limited’s existing procedures already require operators to 
arrange appropriate assistance based on the information provided, regardless 
of whether the person in need is the service user. Assistance was arranged in 
accordance with those procedures in this case. 

Concern 3 
Appello Careline Limited accepts that, in this case, certain information 
indicating deterioration in Mr Burt’s condition was not communicated to the 

 
 
 
 
 
 
 ambulance service. It is Appello Careline Limited’s position that this 
represented an individual failure to fully adhere to established procedures, 
rather than a deficiency in those procedures. 

The matter has been addressed as an individual performance and disciplinary 
issue. In addition, the incident has been incorporated into Appello Careline 
Limited’s ongoing organisational learning processes. 

Appello Careline Limited operates a structured programme of continuous 
improvement, including regular call audits, training updates and monthly 
operational review sessions. These processes include the review of call 
handling against recorded call data and audit outcomes to ensure that 
learning is embedded in operational practice and that operators consistently 
apply required procedures. 

Concerns 4 and 5 
Appello Careline Limited understands that these concerns relate to the 
ambulance service’s internal processes, including note taking and clinical 
triage decision-making. 

These matters fall within the remit and responsibility of the relevant 
ambulance service. Appello Careline Limited will continue to cooperate with 
emergency services and support effective information sharing in line with its 
responsibilities. 

Concern 6 
Appello Careline Limited does not currently deploy AI-based tools for 
automated note taking or decision-making within its call handling processes. 
References during the inquest were to potential future developments rather 
than current practice. 

Appello Careline Limited considers that its existing procedures, supported by 
ongoing training, audit and continuous improvement processes, provide a 
robust framework for managing the risks identified in this case. 

5. 

DETAILS OF FURTHER ACTION PROPOSED 
Any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

Concern 1 
Following operational and technical review, Appello Careline Limited does 
not consider that routinely offering three-way (conference) calling would be 
proportionate or effective, given the operational complexity and variability of 
call scenarios. 

However, Appello Careline Limited has identified an opportunity to 
strengthen the information provided to emergency services in circumstances 
where direct telephone contact is not possible. Appello Careline Limited 
therefore intends to introduce a proportionate enhancement to its triage 
process. 

Operators will be required to establish whether the individual or individuals 
involved have access to a telephone and, where telephone access is not 
available, this fact will be explicitly communicated to the emergency service 

 at the point of referral. 

This measure is intended to ensure that emergency services have sufficient 
information to determine appropriate clinical triage and escalation, without 
introducing operational steps that may adversely affect call handling 
efficiency or service availability. 

Concern 2 
Appello Careline Limited intends to update its operator training materials to 
clarify that calls may be received where assistance is sought for another 
person, for example a household member or visitor. 

The updated guidance will confirm that, in such circumstances, operators 
are expected to apply standard call-handling and triage procedures in the 
same way as if the service user themselves required assistance. 

This represents a clarification of existing expectations rather than a 
substantive change in procedure and is intended to ensure consistency of 
understanding across the operator workforce. 

Concern 3 
Appello Careline Limited will continue to reinforce adherence to established 
procedures through its ongoing training, audit and supervision processes, 
including the use of call audits and operational review mechanisms to 
ensure that relevant information is consistently captured and communicated. 

Appello Careline Limited does not consider that further procedural change is 
necessary at this time. 

Concerns 4 and 5 
No further action is proposed by Appello Careline Limited in respect of these 
concerns, as they fall within the remit and responsibility of the relevant 
ambulance service. 

Concern 6 
Appello Careline Limited will continue to monitor developments in relevant 
technologies, including those relating to call handling and note taking, and 
will consider their use where they can demonstrably improve outcomes. 

Any future implementation would be subject to appropriate governance, 
testing and risk assessment to ensure safety, accuracy and compliance with 
applicable legal and regulatory requirements. 

6. 

 (LEGAL & COMPLIANCE DIRECTOR, APPELLO GROUP)

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT
FUTURE DEATHS

Please do not include any living person names in this document, in accordance
with the Chief Coroner’s publication policy PDF.

THIS RESPONSE IS BEING SENT TO:

The Senior Coroner, for the Coroner Area West Sussex, Brighton and Hove in
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’
following an investigation into the death of Derek Thomas BURT, and an inquest that
concluded on 02 June 2026.

1.

RESPONDENT

In line with our duty under Regulation 29 of the Coroners (Investigations)
Regulations 2013, The Association of Ambulance Chief Executives (AACE)
provides this response within 56 days of the date of the Report to Prevent
Future Deaths or any extension granted.

2.

DATE OF RESPONSE

10 August 2026

3.

CONFIRMATION OF CORONER’S MATTERS OF CONCERN

The MATTERS OF CONCERN were identified in the report are as follows:

The MATTERS OF CONCERN are as follows:
Overall, I accept this was an unusual set of circumstances in that the call to
emergency services was made by a careline operator who was relaying
information from the patient’s wife who was herself the careline user and she
was bedbound so not in a position to assist her husband who was bleeding
heavily and non-responsive, nor could she get to a phone to answer (as it was
in another room) the numerous calls made by the EMA and ambulance clinical
safety navigator.

That said, no one appears to have thought that the Appello careline system
could have been used to speak to Mrs Burt via a third-party conference call as
that is the very method used to call for help and she used it successfully, not
once, but twice. I am concerned that this system and technology is utilised
fully to potentially give vital clinical advice that may save future lives.

1) I heard evidence from the call centre manager of Appello Careline and the
first careline operator that their system has the capability to speak directly to
Mrs Burt without her pressing her wrist alarm button as this could have been
done via the digital base unit that was in her bedroom.  The system can also

 set up a 3 way conversation or conference call to include any of the
emergency services.  Indeed the operator told me she has done this in the
past if asked to do so by the emergency services or she has suggested it but
she did not do so in this case as she took her lead from the EMA.

Conversely, I heard from a clinical safety navigator (CSN) with SECAMB that
she did not know careline companies could set up 3 way conference calls for a
CSN to speak to the patient or helper directly. She knew that Police and Fire
Services used 3 way conference calls using careline systems but not
Ambulance Trusts.

This case had moved from the dispatch to the clinical stack and from the
timeline of calls supplied it seems 15 calls were made between 22:52 and
23:23 to the landline and mobile numbers supplied but of course, it was
impossible for Mrs Burt to answer them.  No one thought to go back through
the digital base unit to offer the basic clinical advice that was needed.  I am
concerned that both Ambulance Trusts generally as well as Careline
companies may not be aware of the potential to save lives using available
technology.

2) I also heard from the careline centre manager that Appello does not have
any specific documentation, training material or guidance that considers calls
for assistance made by the service user for people other than themselves.  It
was good to learn that both careline operators did respond positively to the cry
for help from Mrs Burt.  I remained concerned however that there is no policy
or guidance available for operators to cover this type of emergency or life
threatening situation and no training has yet been devised to learn from the
unusual circumstances that occurred here.

3) I also remain concerned that the first careline operator did not pass on a
key piece of information to the EMA, namely that the caller did not have
access to a phone.  Nor did she ask if the blood was spurting or dribbling.
Although, it was relayed that Mrs Burt was bedbound, the EMA would not have
realised that Mrs Burt couldn’t get to the phone as it was in another room.

In addition the first careline operator did not call the EMA back when she
learned Mr Burt was non responsive and had developed breathing problems.
The CSN confirmed to me that if a second call had been made at that point
then the call would have been upgraded to category 1.  This would have been
at approx 22:50.  In other words around the same time the EMA was trying to
call Mrs Burt back.  The clinical review was allocated at 22:55 and the second
999 call was logged at 23:15 so approximately 20-25 mins had elapsed.

4) Likewise I heard from the SECAMB CSN that she had carried out an audit
of the EMA notes added to their system when speaking to the first careline
operator. She did so from a clinical perspective and she discovered missing
information that was given but not recorded at all namely: that there had
already been 20 minutes of bleeding at the time of the first call (approx.
22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was
bedbound therefore could not assist Mr Burt. None of this information was

 therefore available to the CSN who carried out the clinical review.

In addition I heard that the end to end review carried out by SECAMB and
focused on the dispatch difficulties that existed on 14 May 2025. I appreciate
that the dispatch and clinical review systems were different at that time and
have now been changed but I remain concerned that the quality of note taking
has not been properly checked and action taken to rectify then make
improvements with any individual concerned as well as capturing learning
points for others. Here vital information was missing and was needed to
ensure an effective clinical review could take place and thereby ensure that
the category of call response is accurate.

I was told this call had been audited and was found to be 95% compliant. This
also calls into question the quality of the call auditing system

5) I heard that an EMA can hold a call and speak to a CSN to get basic first
aid advice or join the CSN into the call. Given the volume of blood that had
already been lost in this case, I am concerned that this opportunity to give
clinical advice was lost especially as the call had come in via a careline
operator.

6) I was told that SECAMB is taking part in a pilot called Tortoise looking at
using AI to improve the accuracy of note taking. It was unclear whether a
similar scheme is being explored by careline companies or if there is effective
liaison between careline companies and ambulance trusts.

4.

DETAILS OF ACTION TAKEN, how has the concern been addressed.
[If no action is proposed please explain why here. If you feel that the
response should not have been sent to you, please state this].

Any links to webpages included in the response will not be checked for
sensitive information prior to publication, as the information is already online.

AACE is a private company owned by the English and Welsh Ambulance NHS
trusts. It exists to provide ambulance services with a central organisation that
supports, co-ordinates and assists with the implementation of nationally agreed
policies and guidance. It is a membership organisation representing all UK NHS
ambulance services and our primary focus is the ongoing development of
ambulance service provision and the improvement of patient care. AACE possess
the intellectual property rights of the Joint Royal Colleges Ambulance Liaison
Committee (JRCALC) UK ambulance service clinical practice guidelines (the
“JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance
services; however, it has national influence via the regular meetings of ambulance
chief executives and chairs, along with a network of national specialist groups.

With respect to the matters of concern in relation to the care of Derek Burt, AACE is
not in a position to respond; the specific details relate to and should subsequently be
addressed by both Appello and SECAmb.

 However, within its remit as a membership organisation for UK NHS ambulance
services, AACE does share learning from PFDs across the sector.  In relation to this
specific PFD report, we recognise that the points of concern relate to:

1.  The failure to make use of the careline facility to hold three-way calls with

their user and the ambulance service (either the EMA or CSN);

2.  The fact that the user not having access to a landline or mobile was not

made clear to the ambulance service;

3.  The absence of guidance for the careline operator on management of calls

for assistance made by their user on behalf of another person;

4.  The absence of key clinical details in the information passed by the careline

operator to the EMA, and the failure to update SECAmb when further
information on the deterioration of Mr Burt became apparent;

5.  Missing information in the notes recorded by the EMA which would have

aided the CSN in their clinical review of the case

We will comment on each of these in turn, which we hope proves helpful although
not AACE’s specific remit in relation to this specific case.

1. We were unaware, at a national level, of the facility for ambulance services to hold
three-way conference calls with careline operators and their users. We do consider
that the use of this function would be extremely helpful in certain circumstances
where there is any ambiguity as to the acuity of the clinical condition of the user /
person needing assistance.  AACE has shared and discussed this PFD with the
ambulance service medical directors group (NASMeD) and have recommended that
each ambulance service reviews their own local procedures into handling calls from
telecare providers and to establish if three-way calling is available.

We note Appello’s response in relation to three-way calling - that they believe
routinely offering this facility would not be proportionate or effective – and in the
most part we would agree with this. However, we would advocate that the availability
of such a facility should be made known to all ambulance services by any careline
operator, so that a request to use it can be made by either party, if the need arises.
We understand that Appello, and other careline operators, may not wish to introduce
specific operational steps that prompt the use of three-way calling.  This could be
due to their concern that this may adversely affect their call handling efficiency or
service availability (it would mean their operator would need to stay on the line for
longer)  however, we would argue that the need and ability to ensure the user
receives the appropriate response in a timely manner (which may or may not be an
ambulance) should be paramount in these circumstances.

2. We believe the fact that the user was unable to take a call directly from the
ambulance service should not only have been made known to the EMA but should
also have automatically instigated the option to have a three-way call with the user.
In our view, this protocol needs to be introduced into all careline providers’
operational guidance.

 3. This specific issue is not one AACE is able to offer a view upon.

4. The issue of obtaining sufficient and pertinent details from careline operators
when passing calls to 999 has been a matter of concern for us for a number of
years. We will address this below in additional information.

5. Missing information in records made by the EMA is unfortunate and will no doubt
be addressed by SECAmb. The opportunity to reduce such errors through the use of
AI is indeed being tried and tested by ambulance services now that such innovations
are becoming available. Tortus is the ambient voice technology being trialled in
several services, with the intention of sharing learning and evaluation across the
sector.

Additional information from a national perspective:

AACE began liaising with the TSA (TSA - the voice of TEC) in 2016. The TSA is the
industry body for Technology Enabled Care (TEC) services that provide support to
individuals in their home using a range of technologies such as a basic pendant
alarm, motion or fall detectors, or door, fire and gas sensors, that automatically
contact a response centre staffed 24/7.  Providers of these services vary
considerably from private profit-making companies to those run by local councils;
they also vary greatly in the geographic and population range they cover.  At the
time we began engaging with TSA, they had 350 member organisations and
estimated that these telecare providers were making approximately 1.25million calls
to 999 a year. This figure will no doubt have increased since then.

TEC providers play a vital role in supporting the independence, health and safety of
older and vulnerable people and in doing so, it is essential that they can
demonstrate the quality and safety of the service they operate. However, there is
currently no statutory regulation of TEC providers, which is something the TSA was
lobbying the government for. Together we approached NHS England to discuss
these concerns and the impact that the increasing number and variety of careline
monitoring services were having on 999 demand.

The absence of national regulation creates disparity in the services ultimately offered
to service users. It also  has the potential to increase risk to service users and place
inappropriate demands on 999 services. Those telecare providers registered with
the TSA are expected to adhere to a quality services framework that promotes
consistently safe practices and appropriate use of ambulance services. Those
organisations operating outside of the TSA framework have their own standards,
which are likely to vary depending on the services they choose to provide.

The aims for both our organisations, when we began working together, was to
consider how we could reduce risk and improve the care of telecare users by
ensuring they received the most appropriate response in a timely way. This included:
encouraging telecare providers to establish their own trained and equipped
response teams e.g. for people who have had a fall;

 ensuring all users provide their careline service with an up-to-date list of
relatives/neighbours/wardens who have access to their property and can be
contacted immediately in the event of an emergency to get to them assistance and
‘eyes-on’ quickly while emergency services are contacted – particularly important in
the event of ‘silent and false alarm’ calls to avoid 999 resources being sent
unnecessarily. (This would have helped immensely in the case of Mr Burt).
improving and standardising the type and quality of information a careline operator
asks their user when they press their alarm, to better support the clinical triage
process when they contact 999
developing a decision-support tool - which underpins the interaction between the
user and careline operator, assessing the level of risk and urgency to determine the
appropriate response – which may include calling 999.

We were able to make some steady progress with TSA colleagues prior to the
COVID-19 pandemic and took some specific actions with them during the pandemic
to support their users as procedures and protocols clearly had to change throughout
this period.

The critical element of our work with them relates to the development of a decision-
support tool. TSA did not have the appropriate level of clinical governance to support
this, and AACE and its members are not in a position to offer this.

Following liaison with NHS England, it was agreed that this work would continue
under their stewardship. In 2023 the TSA published their Decision Support Tool
Guidance, and a TEC Call Handling Support Tool.

AACE is not aware if there is any ongoing engagement between the TSA and NHS
England.

5.

DETAILS OF FURTHER ACTION PROPOSED
Any links to webpages included in the response will not be checked for
sensitive information prior to publication, as the information is already online.

AACE will re-engage with the TSA in an effort to reinforce the learning from this case
and the subsequent PFD.

6.

SIGNATURE

, Managing Director, AACE

Ms Karen Taylor  
HM Assistant Coroner  
West Sussex, Brighton and Hove 
The Coroner’s Office 
Woodvale  
Lewes Road  
Brighton  
BN2 3QB 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

30 July 2026  

Dear Ms Taylor,   

Re: Regulation 28 Report to Prevent Future Deaths – Derek Thomas Burt who 
died on 15 May 2025  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  16 
June 2026 concerning the death of Derek Thomas Burt on 15 May 2025. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Mr  Burt  family  and  loved  ones.  NHS  England  is  keen  to 
assure the family and yourself that the concerns raised about Mr Burt’s care have been 
listened to and reflected upon.   

Your Report raises the following concerns:  

1.  Ambulance Trusts may not be aware that the careline system is able to set up 
three-way conversations or conference calls so that emergency services can 
be included in their conversation with the careline user.  

2.  There  is  no  specific  guidance  for  Apello  Careline  operators  regarding 

emergency calls made to them by their service users.  

3.  The  careline  operator  did  not  pass  on  key  information  to  the  Emergency 
Medical Adviser (EMA) relating to the caller’s lack of access to a phone and the 
nature of the bleed. They also did not call them back when the patient became 
unresponsive.   

4.  Concerns were raised that the quality of the note taking by the EMA at South 
East  Ambulance  Service  (SECAMB)  had  not  been  adequately  checked  nor 
actions taken to rectify the individual’s note keeping deficiencies. This raised 
concerns with the quality of the call auditing system.  

5.  An opportunity was lost where the EMA could have obtained clinical advice at 

an earlier opportunity.  

6.  It was unclear whether careline companies are also exploring a trial of artificial 

intelligence equipment to improve accuracy of note taking.  

Concerns 2,3. and 6 relate to the Apello Careline company, and as such are not within 
NHS England’s remit to comment on. As your Report has also been addressed to the 
Apello Careline company they will be best placed to respond to these concerns.  

                                                                                                                       
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 NHS England’s Ambulance Team have reviewed this Report and have advised that 
the concerns raised relate to operational matters, which are the responsibility of the 
local ambulance service; SECAMB NHS Foundation Trust, who will be  best placed to 
respond to the concerns raised. We note that SECAMB have also been addressed in 
your Report and will respond directly to the concerns.  

SEACAMB  have  advised  the  NHS  England  South  East  Regional  team  of 
improvements they have made as a result of your Report, which they will outline in 
their response.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Mr 
Burt are shared across the NHS at both a national and regional level and helps us to 
pay close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT 
FUTURE DEATHS 

Please do not include any living person names in this document, in accordance with 
the Chief Coroner’s publication policy PDF. 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, [X] for the Coroner Area West Sussex, Brighton and Hove in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an 
investigation into the death of Derek Thomas BURT, and an inquest that concluded on 02 
June 2026. 

1.  RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 
2013, NAME provides this response within 56 days of the date of the Report to 
Prevent Future Deaths or any extension granted. 

2.  DATE OF RESPONSE 

3.  CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

The MATTERS OF CONCERN are as follows:  
Overall, I accept this was an unusual set of circumstances in that the call to 
emergency services was made by a careline operator who was relaying information 
from the patient’s wife who was herself the careline user and she was bedbound so 
not in a position to assist her husband who was bleeding heavily and non responsive, 
nor could she get to a phone to answer (as it was in another room) the numerous calls 
made by the EMA and ambulance clinical safety navigator.   

That said, no one appears to have thought that the Appello careline system could have 
been used to speak to Mrs Burt via a third party conference call as that is the very 
method used to call for help and she used it successfully, not once, but twice. I am 
concerned that this system and technology is utilised fully to potentially give vital 
clinical advice that may save future lives. 

1) I heard evidence from the call centre manager of Appello Careline and the first 
careline operator that their system has the capability to speak directly to Mrs Burt 
without her pressing her wrist alarm button as this could have been done via the digital 
base unit that was in her bedroom.  The system can also set up a 3 way conversation 
or conference call to include any of the emergency services.  Indeed the operator told 
me she has done this in the past if asked to do so by the emergency services or she 

 
 
 
 
 
 
 has suggested it but she did not do so in this case as she took her lead from the EMA.   

Conversely, I heard from a clinical safety navigator (CSN) with SECAMB that she did 
not know careline companies could set up 3 way conference calls for a CSN to speak 
to the patient or helper directly. She knew that Police and Fire Services used 3 way 
conference calls using careline systems but not Ambulance Trusts.  

This case had moved from the dispatch to the clinical stack and from the timeline of 
calls supplied it seems 15 calls were made between 22:52 and 23:23 to the landline 
and mobile numbers supplied but of course, it was impossible for Mrs Burt to answer 
them.  No one thought to go back through the digital base unit to offer the basic clinical 
advice that was needed.  I am concerned that both Ambulance Trusts generally as 
well as Careline companies may not be aware of the potential to save lives using 
available technology. 

2) I also heard from the careline centre manager that Appello does not have any 
specific documentation, training material or guidance that considers calls for 
assistance made by the service user for people other than themselves.  It was good to 
learn that both careline operators did respond positively to the cry for help from Mrs 
Burt.  I remained concerned however that there is no policy or guidance available for 
operators to cover this type of emergency or life threatening situation and no training 
has yet been devised to learn from the unusual circumstances that occurred here. 

3) I also remain concerned that the first careline operator did not pass on a key piece 
of information to the EMA, namely that the caller did not have access to a phone.  Nor 
did she ask if the blood was spurting or dribbling.  Although, it was relayed that Mrs 
Burt was bedbound, the EMA would not have realised that Mrs Burt couldn’t get to the 
phone as it was in another room.   

In addition the first careline operator did not call the EMA back when she learned Mr 
Burt was non responsive and had developed breathing problems.  The CSN confirmed 
to me that if a second call had been made at that point then the call would have been 
upgraded to category 1.  This would have been at approx 22:50.  In other words 
around the same time the EMA was trying to call Mrs Burt back.  The clinical review 
was allocated at 22:55 and the second 999 call was logged at 23:15 so approximately 
20-25 mins had elapsed. 

4) Likewise, I heard from the SECAMB CSN that she had carried out an audit of the 
EMA notes added to their system when speaking to the first careline operator. She did 
so from a clinical perspective and she discovered missing information that was given 
but not recorded at all namely: that there had already been 20 minutes of bleeding at 
the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; 
and Mrs Burt was 
bedbound therefore could not assist Mr Burt. None of this information was therefore 
available to the CSN who carried out the clinical review. 

 In addition, I heard that the end to end review carried out by SECAMB and focused on 
the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and 
clinical review systems were different at that time and have now been changed but I 
remain concerned that the quality of note taking has not been properly checked and 

 
 
 
 
 
 
 
 
 
 action taken to rectify then make improvements with any individual concerned as well 
as capturing learning points for others. Here vital information was missing and was 
needed to ensure an effective clinical review could take place and thereby ensure that 
the category of call response is accurate.  

I was told this call had been audited and was found to be 95% compliant. This also 
calls into question the quality of the call auditing system  

5) I heard that an EMA could hold a call and speak to a CSN to get basic first aid 
advice or join the CSN into the call. Given the volume of blood that had already been 
lost in this case, I am concerned that this opportunity to give clinical advice was lost 
especially as the call had come in via a careline operator.  

6) I was told that SECAMB is taking part in a pilot called Tortoise looking at using AI to 
improve the accuracy of note taking. It was unclear whether a similar scheme is being 
explored by careline companies or if there is effective liaison between careline 
companies and ambulance trusts. 

4. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 
[If no action is proposed please explain why here. If you feel that the response should 
not have been sent to you, please state this]. 
Any links to webpages included in the response will not be checked for sensitive 
information prior to publication, as the information is already online. 

Concern 1 

SECAMB acknowledges the Coroner's concern (1) regarding awareness and utilisation 
of Careline technology, including the ability to facilitate direct communication with 
service users and establish three-way conference calls involving ambulance service 
clinicians. 

The Trust has reviewed the learning arising from this inquest and has amended its local 
operating procedure relating to failed callback processes. This guidance now 
specifically includes circumstances where calls originate from Careline providers. 

The revised procedure requires clinicians, where direct contact with the patient or caller 
cannot be established, to contact the Careline provider to determine whether there have 
been any updates or changes to the patient's condition. The guidance also directs staff 
to explore whether the Careline provider can facilitate a three-way conference call, 
enabling direct communication between the clinician and the patient where this 
functionality is available. 

The Trust recognises the potential benefits of utilising Careline technology to support 
clinical assessment and the provision of appropriate advice in circumstances where 
conventional telephone contact is not possible. In addition to the changes already 
implemented within the clinical callback process, SECAMB is currently reviewing how 
similar functionality may be utilised by Emergency Medical Advisors at the point of the 
initial 999 call. This work remains ongoing and no final solution has yet been agreed; 

 
 
 
 
 
 
 
 however, the Trust is committed to identifying opportunities to improve communication 
pathways and maximise the effective use of available technology. 

Concern 3 

SECAMB also acknowledges the Coroner's concern (3) regarding the impact that 
incomplete information sharing and the inability to establish direct contact with the caller 
may have had on the subsequent clinical assessment of this incident. 

Following review of the learning arising from this case, the Trust has amended its failed 
callback procedure to ensure that where information is available indicating that a caller 
or patient cannot access a telephone, clinicians are required to consider alternative 
routes of communication, including re-contact with the originating careline provider 
where appropriate. 

The Trust will reinforce the importance of reassessing incidents whenever additional 
information indicating deterioration in a patient's condition becomes available, whether 
this information is received directly from the patient, a relative, a careline provider or 
another third party. This learning will be incorporated into staff communications and 
ongoing operational training. 

Concern 4 

SECAMB acknowledges the Coroner's concern (4) regarding the completeness of 
information recorded within the emergency call record, the impact this may have had on 
subsequent clinical review, and the effectiveness of the audit process in identifying 
deficiencies in documentation. 

The Trust has also reviewed the audit findings associated with this case. During that 
review it was identified that documentation quality forms a relatively small component of 
the current NHS Pathways audit framework. SECAMB has discussed this concern with 
NHS Pathways, recognising the Coroner's observations regarding the significance of 
missing or inaccurate information within call records. As the national audit framework is 
owned and maintained by NHS Pathways, any review of the weighting applied to 
documentation standards sits within their remit. SECAMB will continue to contribute to 
discussions and share learning where opportunities for improvement are identified. 

The learning arising from this case has also informed local discussions regarding the 
assessment of documentation quality within assurance and audit processes, with a view 
to ensuring that significant omissions within call records are identified, escalated and 
addressed through appropriate learning and improvement activity. 

In addition, the circumstances of this case and the learning identified during the inquest 
have been reviewed through the Trust's governance processes and shared with 
relevant operational and educational leads. 

 
 
 
 Concern 5 

SECAMB acknowledges the Coroner's concern (5) that opportunities may exist to utilise 
available clinical support during complex or unusual calls to ensure that appropriate 
clinical advice is provided at the earliest opportunity. 

The Trust's operating model enables Emergency Medical Advisors (EMAs) to access 
real-time clinical support from clinicians, including Clinical Safety Navigators, when 
additional advice, guidance or decision-making support is required. This includes 
circumstances where calls present with complex clinical needs, unusual circumstances 
or communication challenges. 

Following the learning identified through this inquest, SECAMB has commenced a 
review of how access to clinical inline support is utilised within the Emergency 
Operations Centre. As part of this work, the Trust will be relaunching communications 
and guidance to remind staff of the availability of clinical support and to reinforce 
expectations that clinicians should be engaged where calls present with complexity, 
uncertainty or circumstances that would benefit from additional clinical input. This 
process has now been formally added to the Emergency Operations Centre Call 
Handling Procedure which is currently going through the final steps of Trust governance 
ahead of publication, where it will reinforce with our call handlers the need to seek 
clinical support whenever they feel the need to or the call is outside their scope of 
practice. It is anticipated this will be concluded by the end of Quarter 2. 

This work aims to strengthen awareness and utilisation of existing escalation pathways, 
ensuring staff are supported to access clinical expertise whenever required and helping 
to maximise opportunities for timely clinical advice to patients and callers. 

5.  DETAILS OF FURTHER ACTION PROPOSED 

Concern 4 

SECAMB acknowledges the Coroner's concern (4) regarding the completeness of 
information recorded within the emergency call record, the impact this may have had 
on subsequent clinical review, and the effectiveness of the audit process in identifying 
deficiencies in documentation. 

The Trust fully recognises that accurate and comprehensive documentation is 
essential to support effective clinical assessment, review and decision-making 
throughout a patient's journey. Whilst emerging technology may offer future 
opportunities to improve the capture of information, SECAMB does not consider that 
current solutions are sufficiently developed for implementation within Emergency 
Medical Advisor (EMA) call handling processes at this time. 

The Trust is currently participating in trials of Tortus AI technology to support clinical 

 
 
 
 note taking. However, this technology is presently focused on clinical applications and 
is not yet at a stage where its use within the emergency call handling environment is 
considered practicable. Separately, work is ongoing across the sector to explore 
automated call auditing and transcription solutions. Cleric CAD, amongst other 
providers, is investigating the potential for live transcription functionality across all 
calls, which may support the completeness and accuracy of information available to 
clinicians and operational teams in the future. 

Whilst these longer-term technological developments continue to be explored, the 
Trust has taken immediate action by raising the learning identified through this 
inquest with the Training Department. A review is underway to determine what 
enhancements can be made to training, guidance and development processes to 
further support Emergency Medical Advisors in accurately documenting information 
obtained during emergency calls.  This will be in place by the close of the financial 
year. 

The Trust is reviewing how documentation quality is considered within local 
assurance processes to ensure that significant omissions within call records can be 
more readily identified, escalated and addressed through learning and improvement 
activity. 

SECAMB acknowledges the Coroner's concern (6) regarding the role that emerging 
technologies and partnership working may play in improving communication, 
information sharing and patient outcomes. 

As outlined elsewhere within this response, the Trust has identified opportunities to 
strengthen its understanding of the capabilities available through Careline providers 
and to improve how these capabilities can be utilised within ambulance service 
operations. This learning has informed broader discussions regarding collaborative 
working with Careline providers operating within the Trust's footprint. 

The Trust is currently progressing work through its Falls and Frailty Pathways of 
Care, within which closer engagement and partnership working with Careline 
providers has been identified as a key area of development. This work will provide 
opportunities to improve mutual understanding of organisational processes, 
escalation pathways, communication methods and technological capabilities, 
ensuring that available resources can be utilised more effectively in support of 
patients requiring urgent care. 

The Trust will also seek to use these partnership arrangements to share learning 
arising from this case, including consideration of circumstances where telecare users 
seek assistance for another person and the communication challenges that may arise 
in such situations. 

SECAMB recognises the value of fostering strong relationships with Careline 
providers and believes that the ongoing work within the Falls and Frailty Pathways of 
Care will further strengthen these partnerships, support shared learning and help 
identify opportunities for service improvement across organisational boundaries. 

 
 
 The Trust remains committed to exploring both technological and operational 
solutions that enhance communication, improve patient assessment and support safe 
and effective care for patients accessing emergency services through Careline 
systems. 

SECAMB is grateful for the opportunity to consider the concerns raised by HM 
Coroner and the learning identified through the inquest into the death of Mr Burt. The 
Trust has carefully reviewed those matters falling within its area of responsibility and 
has taken steps to implement improvements whilst also identifying further 
opportunities for development. SECAMB remains committed to continuous learning, 
strengthening partnership working, enhancing communication and ensuring that its 
policies, processes and systems support the delivery of safe, effective and patient-
centred care. The Trust will continue to monitor the progress of the actions outlined 
within this response and incorporate learning as part of its ongoing quality 
improvement and governance arrangements. 

6.  SIGNATURE

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT 
FUTURE DEATHS 

Please do not include any living person names in this document, in accordance 
with the Chief Coroner’s publication policy PDF. 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, [X] for the Coroner Area West Sussex, Brighton and Hove 
in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ 
following an investigation into the death of Derek Thomas BURT, and an inquest that 
concluded on 02 June 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the coroners (Investigations) 
Regulations 2013, TEC QUALITY on behalf of the TSA provides this 
response within 56 days of the date of the Report to Prevent Future Deaths or 
any extension granted. 

2. 

7TH August 2026 

3. 

CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

We have been asked to respond to this matter: 

About TSA 

TSA is the industry body for Technology Enabled Care (TEC), working to support the 
transformation of the sector through stronger partnerships, data, and workforce 
development, while responding to the growing opportunities and challenges within 
TEC. 

A key part of our role is promoting the quality and safety of TEC services through the 
development of standards and the provision of independent audit and certification. 
This work is delivered by our wholly owned subsidiary, TEC Quality Ltd, the only UK 
Accreditation Service (UKAS) accredited certification body in the TEC Sector. 

We also support our members through guidance, training, and knowledge sharing to 
improve service delivery, particularly in relation to analogue-to-digital transformation, 
business growth, and sector-wide improvement. 

 
 
 
 About TEC Quality and the Quality Standards Framework 

TEC Quality operates the Quality Standards Framework (QSF), an outcomes-based 
auditing scheme designed to drive quality, consistency, and safety across the TEC 
sector. 

The standards are reviewed annually through a formal scheme change process to 
ensure they remain robust and relevant within an evolving operational and 
technological environment. 

In addition, TEC Quality provides CPD-accredited e-learning programmes, particularly 
aimed at frontline operational staff, to support the development of knowledge, skills, 
and nationally benchmarked best practice. 

Although TEC remains an unregulated sector, the QSF represents the closest 
equivalent to an independently audited quality assurance framework aligned to 
recognised British and European standards. The framework provides Commissioners, 
procurement bodies, Local Authorities, housing providers, and care organisations with 
assurance that appropriate safeguards and quality processes are in place to protect 
Service Users. 

Neither TSA nor TEC Quality were part of the coroner's hearing for this case. 

The MATTERS OF CONCERN identified by the Coroner in the report are as 
follows: 

This was an unusual set of circumstances in that the call to emergency 
services was made by a careline operator who was relaying information from 
the patient’s wife who was herself the careline user and she was bedbound so 
not in a position to assist her husband who was bleeding heavily and non 
responsive, nor could she get to a phone to answer (as it was in another room) 
the numerous calls made by the EMA and ambulance clinical safety navigator.   

That said, no one appears to have thought that the Appello careline system 
could have been used to speak to Mrs Burt via a third party conference call as 
that is the very method used to call for help and she used it successfully, not 
once, but twice. I am concerned that this system and technology is utilised 
fully to potentially give vital clinical advice that may save future lives. 

1) I heard evidence from the call centre manager of Appello Careline and the 
first careline operator that their system has the capability to speak directly to 
Mrs Burt without her pressing her wrist alarm button as this could have been 
done via the digital base unit that was in her bedroom.  The system can also 
set up a 3 way conversation or conference call to include any of the 
emergency services.  Indeed the operator told me she has done this in the 
past if asked to do so by the emergency services or she has suggested it but 
she did not do so in this case as she took her lead from the EMA.   

 
 
 
 
 Conversely, I heard from a clinical safety navigator (CSN) with SECAMB that 
she did not know careline companies could set up 3 way conference calls for a 
CSN to speak to the patient or helper directly. She knew that Police and Fire 
Services used 3 way conference calls using careline systems but not 
Ambulance Trusts.  

This case had moved from the dispatch to the clinical stack and from the 
timeline of calls supplied it seems 15 calls were made between 22:52 and 
23:23 to the landline and mobile numbers supplied but of course, it was 
impossible for Mrs Burt to answer them.  No one thought to go back through 
the digital base unit to offer the basic clinical advice that was needed.  I am 
concerned that both Ambulance Trusts generally as well as Careline 
companies may not be aware of the potential to save lives using available 
technology. 

TEC Quality response to point 1:  

A review of this incident highlights several key areas for consideration and potential 
improvement: 

•  Communication of critical information between agencies in particular ensuring 
that communication pathways for triage of the Service User by the ambulance 
service and clinical teams are available 

•  Clarity and effectiveness of communication pathways. 
•  Availability and utilisation of conference calling functionality within the Appello 

TEC monitoring platforms. 

•  The ability to facilitate conference calling functionality on a wider, national 

scale during emergency response situations. 

In this case, it is difficult to determine whether a different outcome would have 
resulted had information been communicated more effectively between the parties 
involved. However, it is reasonable to consider whether further questioning or 
alternative actions may have been taken had it been clearly communicated that the 
Service User could not be contacted via either their landline or mobile telephone. 

For example, if the Emergency Medical Advisor (EMA) had been advised at the outset 
that direct telephone contact with the Service User was not possible, consideration 
may have been given to establishing an alternative communication route, such as a 
conference call involving the monitoring centre and ambulance service.  Or whether 
localised on-site contact could be found from the Service User’s records and contact 
list. 

It should be noted that conference calling functionality is not universally available 
across TEC monitoring platforms nor is it appropriate in every call to the ambulance 
service. Current intelligence suggests that only a limited number of systems offer this 
capability. Nevertheless, where such functionality exists, monitoring centre operators 
should proactively consider its use when it becomes apparent that a Service User 

 
 
 
 cannot be contacted through conventional telephone channels. In this particular case, 
it could be argued that a more proactive approach to facilitating a three-way 
conversation may have supported information sharing between the parties involved. 

While TEC Quality has no authority to influence or amend national ambulance service 
triage systems, there may be opportunities to strengthen communication processes 
where referrals are made between TEC monitoring centres and ambulance services. In 
particular, where contact details are passed for onward communication, TEC operators 
and EMA’s should ensure that the telephone number provided is active, accessible and 
represents a viable means of communication. 

Consideration could also be given to incorporating additional questions within 
ambulance triage processes, such as: 

• 
• 

Is the Service User able to answer or access a telephone? 
If not, does the telecare system have conference calling capability that could 
facilitate communication between relevant parties? 

More broadly, the incident demonstrates that there were multiple communication 
challenges throughout the response process. Given the severity of the call, it may have 
been beneficial for the ambulance service to re-establish contact with the monitoring 
centre when attempts to contact the Service User proved unsuccessful. This would 
have enabled the sharing of updated information, reassessment of available options, 
and a more coordinated response between agencies. 

2) I also heard from the careline centre manager that Appello does not have 
any specific documentation, training material or guidance that considers calls 
for assistance made by the service user for people other than themselves.  It 
was good to learn that both careline operators did respond positively to the cry 
for help from Mrs Burt.  I remained concerned however that there is no policy 
or guidance available for operators to cover this type of emergency or life 
threatening situation and no training has yet been devised to learn from the 
unusual circumstances that occurred here. 

3) I also remain concerned that the first careline operator did not pass on a 
key piece of information to the EMA, namely that the caller did not have 
access to a phone.  Nor did she ask if the blood was spurting or dribbling.  
Although, it was relayed that Mrs Burt was bedbound, the EMA would not have 
realised that Mrs Burt couldn’t get to the phone as it was in another room.   

In addition the first careline operator did not call the EMA back when she 
learned Mr Burt was non responsive and had developed breathing problems.  
The CSN confirmed to me that if a second call had been made at that point 
then the call would have been upgraded to category 1.  This would have been 
at approx 22:50.  In other words around the same time the EMA was trying to 
call Mrs Burt back.  The clinical review was allocated at 22:55 and the second 

 
 
 
 
 999 call was logged at 23:15 so approximately 20-25 mins had elapsed. 

TEC Quality response to points 2 and 3: 

A review of this incident has identified several key areas for consideration and 
potential improvement: 

•  Service User records, including the accuracy, completeness and ongoing 

maintenance of contact information. 

•  Recording details of additional household members and their potential role as 

responders. 

•  The capability of TEC Monitoring Centres to respond appropriately and their 
responsibility to follow established procedures and escalation pathways. 

At the point of installation, and as part of routine reviews and updates, typically 
undertaken at least annually, TEC providers are expected to maintain accurate and up-
to-date information for each Service User. This information would normally include the 
Service User's name, address, date of birth, relevant medical conditions, GP details, 
contact and responder information, known risk factors (for example, living alone or 
hoarding concerns), and details of any third parties involved in their care, such as 
domiciliary care agencies. 

Where additional household members reside at the property, it would be expected 
that, as a minimum, their name and relationship to the Service User are recorded 
within the Service User record, as they may represent an important source of 
information, contact point, or as a potential responder during a TEC incident. 

From a TEC Monitoring Centre perspective, operators are responsible for assessing 
incoming calls, following established protocols and arranging the most appropriate 
response based on the information available. To support this, TEC Quality provides 
certified organisations with a Decision Support Toolkit (DST) designed to assist non 
medically trained frontline monitoring centre operators in identifying relevant 
symptoms, by asking appropriate incident-specific questions and determining suitable 
escalation pathways. The DST was established through stakeholder collaboration and 
consultation including Central Ambulance Service, NHSE and AACE. 

The DST describes a major bleed may result in death or is life threatening from a 
sudden new injury or from a previous disease or injury and will need an emergency 
clinical response and breathing difficulty information, which includes a comprehensive 
list of descriptors, information prompts and example questions. 

A review of the call recordings suggests that opportunities may have been missed to 
provide the Emergency Medical Advisor (EMA) with information that could have 
informed the triage assessment and potentially supported a higher-priority emergency 
response. Whilst it is not possible to determine whether the outcome would have 
been different, the timely communication of all relevant information remains a critical 

 
 
 component of effective emergency response management. 

It should also be recognised that TEC Monitoring Centre operators manage a diverse 
range of incidents and are not solely responsible for responding to health-related 
emergencies. Their role frequently involves liaising with ambulance, fire and police 
services, alongside managing welfare and reassurance calls. As such, TEC operators are 
expected to possess the skills, knowledge and professional judgement required to 
assess situations effectively and coordinate the most appropriate response in 
accordance with established procedures and best practice and this may not be limited 
to the Service User alone. 

This incident highlights the importance of: 

•  Maintaining comprehensive and regularly updated Service User records. 
•  Recording details of all household members including those who could 

potentially become the service user themselves and thus requiring a response 
or who may act as contacts or responders. 

•  Ensuring that all relevant information is communicated promptly and 

accurately to emergency service partners. 

•  Not making any assumptions but refer back to the Service User for clarity. 
•  Consistently applying established call-handling protocols and decision-support 

tools. 

•  Providing operators with the knowledge, confidence and competence required 
to manage complex incidents and support effective response prioritisation. 

QSF certified organisations should ensure that all TEC Operators complete both in-
house training and the Continuing Professional Development (CPD) learning modules 
provided by TEC Quality as part of the Quality Standards Framework (QSF). TEC Quality 
recommends that the coroner endorses the TSA Quality Standards Framework 
certification for all TEC Providers. 

This will help ensure that TEC operators are equipped to gather, assess and 
communicate critical information effectively to EMA’s and other emergency service 
professionals. 

4) Likewise I heard from the SECAMB CSN that she had carried out an audit 
of the EMA notes added to their system when speaking to the first careline 
operator. She did so from a clinical perspective and she discovered missing 
information that was given but not recorded at all namely: that there had 
already been 20 minutes of bleeding at the time of the first call (approx. 
22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was 
bedbound therefore could not assist Mr Burt. None of this information was 
therefore available to the CSN who carried out the clinical review. 

 In addition I heard that the end to end review carried out by SECAMB and 
focused on the dispatch difficulties that existed on 14 May 2025. I appreciate 

 
 
 that the dispatch and clinical review systems were different at that time and 
have now been changed but I remain concerned that the quality of note taking 
has not been properly checked and action taken to rectify then make 
improvements with any individual concerned as well as capturing learning 
points for others. Here vital information was missing and was needed to 
ensure an effective clinical review could take place and thereby ensure that 
the category of call response is accurate.  

I was told this call had been audited and was found to be 95% compliant. This 
also calls into question the quality of the call auditing system  

5) I heard that an EMA can hold a call and speak to a CSN to get basic first 
aid advice or join the CSN into the call. Given the volume of blood that had 
already been lost in this case, I am concerned that this opportunity to give 
clinical advice was lost especially as the call had come in via a careline 
operator.  

TEC Quality response to points 4 and 5: 

These are internal ambulance processes and TEC Quality are not able to influence nor 
make comment in these areas. 

6) I was told that SECAMB is taking part in a pilot called Tortoise looking at 
using AI to improve the accuracy of note taking. It was unclear whether a 
similar scheme is being explored by careline companies or if there is effective 
liaison between careline companies and ambulance trusts. 

TEC Quality response to points 6: 

Ambulance services, including SECAMB and other NHS ambulance trusts, and 
Technology Enabled Care (TEC) providers operate as separate organisations, with a 
variety of service delivery models in use across the country. While TEC organisations 
are encouraged to establish data-sharing agreements with local ambulance services 
where possible, this can be challenging for national providers operating across 
multiple ambulance trust regions. 

As a result, the primary route for requesting an emergency response remains through 
the standard 999 telephone service. In the vast majority of cases, this process is 
effective and appropriate. At present, there are no nationally established pathways 
that enable information captured through TEC systems, including AI-assisted note-
taking, to be transmitted directly to ambulance services via email or other electronic 
means as part of an emergency referral process. 

The use of AI technology within TEC services to capture and document live call 
information is an emerging area and is not currently embedded as standard practice 
across the sector. All inbound and outbound TEC calls are recorded and retained, 

 
 
 
 
 
 
 
 enabling review for quality assurance, training purposes, and investigation of incidents 
or events by authorised senior personnel. 

Under the TEC Quality Standards Framework (QSF), a minimum of two calls per 
operator are subject to quality assurance review each month, including at least one 
emergency-related call. This process supports ongoing performance monitoring, 
compliance with procedures, and the identification of learning opportunities. 

4. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 
[If no action is proposed please explain why here. If you feel that the response 
should not have been sent to you, please state this]. 

Any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

TEC Quality were provided with the call recordings and further information to support 
the response to the PFD notice.  Further actions are outlined below. 

5. 

DETAILS OF FURTHER ACTION PROPOSED 
Any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

Key Learning to point 1:  

Effective communication, timely information sharing, and the proactive use of 
available technology are critical factors in supporting collaborative decision-making 
between TEC monitoring centres and emergency service partners.  

Opportunities exist to strengthen guidance and operational procedures in these areas 
to help reduce the risk of similar issues occurring in the future and these will be 
addressed through future TEC Quality CPD e-learning programme and through 
strengthened QSF criteria for all certified TEC Monitoring Auditees to ensure the 
quality of TEC call monitoring and response. 

Key Learning to points 2 and 3. 

The review identified significant missed opportunities in information gathering, 
communication, monitoring, escalation and adherence to procedure.  

In response to the learning arising from this incident, TEC Quality will strengthen 
future learning and development programmes, which is a mandatory requirement for 

 
 
 
 
 all QSF-certified organisations, with a particular focus on: 

•  The importance of maintaining accurate and up-to-date Service User records, 

including details of additional household members. 

•  Ensuring that appropriately skilled, knowledgeable and competent operators 

• 

are available to manage incoming calls. 
Implementing robust training, competency assessment and continuing 
professional development programmes. 

•  Reinforcing the use of the TEC Quality Decision Support Toolkit, or an 

equivalent approved in-house system, to ensure operators ask relevant 
incident-specific questions and follow appropriate escalation pathways. 
•  Strengthening operators' understanding of the information required by 

emergency service partners to support informed triage and response decisions. 

These actions will support continuous improvement across the sector and help 
maximise the effectiveness of TEC services in responding to emergency situations. 

Key Learning Points for point 6 

TEC Quality and AACE (the Association of Ambulance Chief Executives) have a well-
established partnership and a proven track record of working collaboratively to 
address issues such as this. This close working relationship will continue, ensuring that 
the interests of both the TEC and ambulance sectors are effectively represented. 

6. 

SIGNATURE 

Head of Quality and Improvement 
TEC Quality