“Although I received reassurance following the internal investigation that actions have…”

The coroner’s concerns

– (1) Although I received reassurance following the internal investigation that actions have been completed and lessons learnt in relation to this death, I remain concerned about the fact that the ambulance crew and paramedic were entirely unaware of the familiar faces plan in place for Sophie which contained crucially important information pertinent as to how best to assist her, secure her engagement and in relation to issues of both capacity and risk. I was told in evidence that the difficulty related to a data limit upon the electronic devices utilised by NEAS, and that therefore there should be a flag on electronic communications and that the control room would need to be contacted to obtain the additional information. NEAS were a signatory to the multi agency familiar face plan in this case which applies to them as well as a number of other agencies and was designed to assist in supporting the deceased and to reduce the risk of harm. (2) I am concerned that the information was not seen by the ambulance crew and paramedic who attended, and I am not reassured that it will be available to first responders on future occasions as it seems that the limits of the technology require the ambulance crew or paramedic to spot the flag and to contact the control room, presumably for a verbal account of the information only. I am concerned that in an emergency situation and when services are under such pressure that crucial information, such as a multi agency familiar face plan is not easily accessible to those attempting to offer assistance to some of the most vulnerable people in society. 2

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0427

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0