Example narratives

OA // 1 x M ♂ | 27yo | no other resources req’d | Pt found slumped in armchair and leaning to the left.
OA // 1 x F ♀ | 12yo | Pt found in bed, cuddled up to her mother. Evidence of vomit on PJ’s.

Prompts to include

• How many patients are there at the scene?

• How old is the patient(s)?

• Do we need any extra resources? M/ETHANE?

• Sex: is the patient F or M?

• Where is the patient at the scene?

• Was the patient prone/supine/weight bearing/sat upright?

Presenting complaint is it (Medical, Trauma or Surgical)?

Prompts to include

• What was the main reason for calling us today?

• Who made the call for help — the patient or a relative?

Example narratives

PC // MEDICAL | CCP central chest pain | Call made by patient’s son
PC // TRAUMA | Penetrating injury to chest | Call made unknown passer-by

HPC Template 1 (General, works for most calls)

HPC // Pt reports [main symptom] for [duration]. Onset [sudden/gradual] at [time] while [activity]. Symptoms [constant/intermittent], currently [severity/impact]. Associated symptoms: [+/- SOB, N/V, dizziness, fever, cough, abdo pain, headache, weakness, rash, urinary symptoms, bleeding]. Denies: [key red flags relevant to presentation]. Self-treatment: [none/analgesia/inhaler/GTN/etc] with [effect]. No recent [trauma/travel/ill contacts/new meds].

HPC Template 2 (Pain-focused OPQRST)

HPC // Pain [location], onset [time], [sudden/gradual]. Provoked by [movement/exertion/food/breathing], relieved by [rest/position/meds]. Quality [sharp/dull/pressure/burning/colicky]. Radiation to [site]. Severity [x/10] (max [x/10]). Time course [constant/intermittent/worsening]. Associated: [symptoms]. Denies: [red flags].

HPC Template 3 (Breathing / respiratory)

HPC // SOB for [duration], onset [sudden/gradual]. Worse with [exertion/lying flat], able to speak in [full sentences/short phrases]. Cough [dry/productive], sputum [colour], fever [yes/no], chest pain [yes/no], wheeze [yes/no]. Recent [infection/contact/travel]. Inhalers/nebs used [yes/no] with [effect]. Baseline function [normal/reduced].

Two complete examples (so it reads like your model)

Example: Chest pain

HPC // Pt reports central chest tightness for 45 mins, sudden onset at rest while watching TV. Constant pressure-type pain, radiates to L arm, severity 8/10. Associated diaphoresis and nausea. Denies syncope, haemoptysis, recent illness or trauma. No relief with rest. No meds taken prior to crew arrival.

Example: Falls / hip pain

HPC // Pt reports mechanical fall at home approx 30 mins PTA after tripping on rug. Landed on R side. Immediate R hip/groin pain, unable to weight bear since. Pain sharp on movement, 7/10, relieved slightly at rest. Denies head strike, LOC, neck/back pain, anticoagulant use, or pre-fall dizziness/chest pain/SOB.

(Priority Symptoms & Initial Clinical Impression)

Newborn / Neonate

OE // Newborn priority symptoms assessed. APGAR score 10/10 (Appearance 2, Pulse 2, Grimace 2, Activity 2, Respirations 2). Infant pink and well perfused, strong cry, good tone, regular respirations, no signs of distress.

Child

OE // Child priority symptoms assessed. Alert and responsive, appears unhappy but fully interactive with carers. Good muscle tone, crying appropriately. No lethargy noted. Breathing effort normal with equal chest movement, no recession, no nasal flaring, and no grunting observed.

Adult

OE // Adult priority symptoms assessed. Patient A&Ox4, maintaining airway and breathing adequately. Good radial pulse present, no evidence of active haemorrhage. FAST assessment negative. Observations recorded in ePCR. New pain reported during assessment — further evaluation undertaken.

Concise alternative (when space is tight)

• OE // Neonate: APGAR 10/10, pink, good tone, strong cry, no respiratory distress.

• OE // Child: Alert, interactive, good tone, normal respiratory effort, no recessions or grunting.

• OE // Adult: A&Ox4, airway patent, breathing adequate, good radial pulse, FAST neg, obs in ePCR.

CVS — Cardiovascular

Considered: chest pain, palpitations, syncope, dizziness, peripheral oedema, exercise tolerance.
Findings: [normal / abnormal – specify].
Example:
CVS // No chest pain, palpitations, or syncope reported. Good peripheral perfusion. No peripheral oedema noted.

CNS — Neurological

Considered: LOC, seizures, headache, weakness, speech or visual disturbance, confusion.
Findings: [normal / abnormal – specify].
Example:
CNS // Alert and orientated, no focal neurology, no seizure activity reported. Speech clear, pupils equal and reactive.

Respiratory

Considered: SOB, cough, wheeze, sputum, chest pain, haemoptysis.
Findings: [normal / abnormal – specify].
Example:
Resp // No SOB at rest, equal chest expansion, no wheeze or added sounds on auscultation.

GI / GU

Considered: abdo pain, nausea, vomiting, bowel habit changes, urinary symptoms, PV/PR bleeding.
Findings: [normal / abnormal – specify].
Example:
GI/GU // Abdomen soft and non-tender, no N/V/D, normal bowel and urinary habits reported.

MSK — Musculoskeletal

Considered: pain, deformity, reduced ROM, weight-bearing ability, recent trauma or falls.
Findings: [normal / abnormal – specify].
Example:
MSK // No deformity or bony tenderness. Full range of movement to all limbs. Mobilising independently.

Skin

Considered: rashes, wounds, bruising, pressure damage, temperature, colour, signs of infection.
Findings: [normal / abnormal – specify].
Example:
Skin // Warm and dry, no rashes or wounds noted. No signs of infection or pressure injury.

Psych — Mental Health

Considered: mood, behaviour, distress, capacity, risk to self or others.
Findings: [normal / abnormal – specify].
Example:
Psych // Mood appropriate to situation. No evidence of acute distress, hallucinations, or suicidal ideation expressed.

Paediatric AX (if applicable)

Considered: interaction, tone, feeding, nappies, rashes, breathing effort, parental concern.
Findings: [normal / abnormal – specify].
Example:
Paeds AX // Child interactive with carers, good tone, feeding as normal, wet nappies reported today. No rashes or respiratory distress observed.

One-Line Systems Review (when space is tight)

Systems review considered: CVS, CNS, Resp, GI/GU, MSK, Skin, Psych (± Paeds). No significant abnormalities identified other than those documented above.

This section is for any history of past medical history, when last seen by GP, last in hospital and why, and any ITU admissions.

It is often useful to ask about common conditions using the mnemonic MJTHREADS:

PMHx //

• M — Myocardial infarction

• J — Jaundice & liver disease

• T — TB

• H — High blood pressure

• R — Rheumatology (skin/joint problems)

• E — Epilepsy or seizures

• A — Asthma or other lung conditions

• D — Diabetes

• S — Stroke or TIA

• ITU — any ITU admissions / none

Example

PMHx // MI x2 (last 2001) | No jaundice or AKI | No hx of TB | HTN | No rheum problems | No hx epilepsy/seizures | No asthma | IDDM since 2009 | CVA x2 (last 2020) | TIA x1 (last 2022)

Document relevant surgical procedures, including:

• Type of surgery

• Approximate year (if known)

• Reason for surgery

• Any complications or ITU admissions related to the procedure

• Date and reason for last hospital admission if relevant

Focus on surgery that influences current risk, assessment, or management.

Example narrative (standard)

PSHx // Laparoscopic cholecystectomy (2009) for gallstones. Coronary stent inserted post MI (2020). No reported surgical complications. No ITU admissions related to surgery.

Example narrative (with ITU admission)

PSHx // Emergency laparotomy for bowel obstruction (2018) requiring post-op ITU admission. Full recovery reported. No further surgical interventions since.

Example narrative (when unclear or limited history)

PSHx // Pt reports previous abdominal surgery, unable to recall exact procedure or date. No recent hospital admissions reported. No known ITU admissions.

Example narrative (negative but documented)

PSHx // No previous surgical history reported. No recent hospital admissions. No ITU admissions.

One-line rapid PSHx (when space is tight)

• PSHx // Cholecystectomy 2009 | Coronary stent post MI 2020 | No ITU

• PSHx // Nil surgical history reported

Drug history should clearly identify what the patient takes, how they take it, and what increases risk in the current presentation.

Focus on accuracy over completeness.

Gold-standard DHx structure

DHx // Current medications [listed]. Allergies [NKDA / drug + reaction]. Compliance [compliant / non-compliant / unclear]. Medications taken in last 4 hours [list or none]. Recent medication changes [yes/no – specify]. Anticoagulant / antiplatelet use [yes/no – specify]. Recreational / illicit drug use [denied / disclosed – specify].

Example narratives (ready to paste)

Standard, low risk

DHx // Ramipril 5 mg OD, Metformin 1 g BD. NKDA. Fully compliant. No medications taken in last 4 hours. No recent medication changes. Not on anticoagulants or antiplatelets. Illicit drug use denied.

High-risk (anticoagulant)

DHx // Apixaban 5 mg BD, Bisoprolol 5 mg OD. NKDA. Compliant. Last dose of apixaban taken approx 2 hours prior to arrival. No recent medication changes. Illicit drug use denied.

Allergy documented properly

DHx // Co-amoxiclav allergy — causes rash and facial swelling. Currently taking Salbutamol inhaler PRN. Compliant. No meds taken in last 4 hours.

Non-compliance / uncertainty

DHx // Prescribed insulin and antihypertensives; compliance poor per patient. Last insulin dose unclear. Medication list verified via patient/carer.

Substance use relevant

DHx // Regular prescribed medications as above. No anticoagulants. Reports recent cocaine use earlier today. No alcohol intake today.

High-Risk Medicines — Always Document Clearly

These must never be implied. State them explicitly.

Anticoagulants (examples)

• Apixaban (Eliquis)

• Dabigatran (Pradaxa)

• Dalteparin (Fragmin)

• Edoxaban (Savaysa)

• Enoxaparin (Lovenox)

• Fondaparinux (Arixtra)

• Heparin (including Innohep)

• Rivaroxaban (Xarelto)

• Warfarin (Coumadin / Jantoven)

Antiplatelets (examples)

• Aspirin

• Clopidogrel (Plavix)

• Dipyridamole (Persantin)

• Prasugrel (Effient)

• Ticagrelor (Brilinta)

Document relevant hereditary or familial conditions that may influence the current presentation or long-term risk.
Focus on first-degree relatives (parents, siblings, children), then second-degree if clinically relevant.

Include:

• Condition

• Relationship (1st or 2nd degree)

• Approximate age at diagnosis or death (if known)

Avoid listing unrelated conditions.

Example narrative (standard)

FMHx // Mother (1st degree) diagnosed with lung cancer at approx. 45 years. Father (1st degree) history of hypertension diagnosed in later adulthood. No known familial cardiac disease reported.

Example narrative (cardiac-relevant)

FMHx // Father (1st degree) MI aged 52. Paternal grandfather sudden cardiac death in 50s. No known familial clotting disorders.

Example narrative (neurological / stroke)

FMHx // Mother (1st degree) CVA aged 61. Maternal aunt (2nd degree) history of TIA. No known family history of epilepsy.

Example narrative (oncology)

FMHx // Maternal aunt (2nd degree) breast cancer diagnosed age 32. Maternal grandmother ovarian cancer in later life. No other significant familial malignancy reported.

Example narrative (negative but documented)

FMHx // No significant family medical history reported that relates to current presentation.

Example narrative (limited or uncertain history)

FMHx // Family medical history unclear. Pt unable to provide further details. No known hereditary conditions reported.

One-line FMHx (when space is tight)

• FMHx // Father MI 52 | Mother HTN | No other relevant family history

• FMHx // Nil relevant family history reported

Social history should focus on factors that affect health, risk, recovery, and safety.
Only document what is relevant to the presentation, but show that it was considered.

A useful prompt structure is LOCAS DIET.

Gold-standard SHx structure

SHx // Living arrangements [who with / alone / supported]. Occupation [or retired/unemployed]. Children [yes/no – caregiving responsibilities]. Alcohol [units/frequency or denied]. Smoking [current/ex/never]. Diet [adequate/poor/reduced]. Exercise [baseline mobility/activity]. Other relevant social factors [support, travel, housing, safeguarding].

LOCAS DIET — What to Include

L — Lives with

• Alone / partner / family / carers / care home

• Relevant to falls risk, safeguarding, discharge planning

O — Occupation

• Working, retired, unemployed, student

• Consider exposure risks, physical demands, stress

C — Children

• Number and ages if relevant

• Caring responsibilities or safeguarding considerations

A — Alcohol

• Units per week or pattern of use

• Recent intake if clinically relevant

S — Smoking

• Current / ex / never

• Quantity and duration if relevant

Di — Diet

• Adequate / reduced / poor

• Recent changes, hydration concerns

E — Exercise

• Baseline mobility and activity level

• Independent / aids / housebound

T — Other relevant factors (local use)
Use this flexibly for what matters now, such as:

• Support network

• Housing issues

• Recent travel

• Financial stress

• Isolation

• Safeguarding context

Example SHx Narratives (Ready to Paste)

Standard

SHx // Lives with partner. Retired. Two adult children not living at home. Drinks alcohol socially. Non-smoker. Diet adequate. Mobilises independently at baseline. Good family support.

Falls / elderly

SHx // Lives alone. Retired. No regular carers. Drinks minimal alcohol. Ex-smoker. Diet variable with reduced intake recently. Baseline mobility with stick indoors. Limited social support.

Mental health

SHx // Lives alone. Currently unemployed. No children. Alcohol intake increased recently. Smokes daily. Diet poor. Limited exercise. Reports social isolation.

Paediatric

SHx // Lives with parents and sibling. Attends school. No safeguarding concerns identified. Normal diet and activity for age.

One-line SHx (when space is tight)

• SHx // Lives alone | retired | minimal support

• SHx // Lives with family | independent baseline

• SHx // Unemployed | ↑ alcohol | socially isolated

IMP // Clinical presentation most consistent with [working diagnosis], based on [key symptoms, examination findings, and observations]. Patient currently [clinically stable / unstable / compensated]. Differential considerations include [significant alternatives], though these are [less likely / cannot be excluded] at this stage.

Example narratives (ready to paste)

Chest pain

IMP // Presentation most consistent with suspected acute coronary syndrome, given central chest pain, radiation to left arm, associated diaphoresis, and cardiac risk factors. Patient currently haemodynamically stable. Differential considerations include musculoskeletal chest pain and anxiety-related symptoms; however, cardiac pathology cannot be excluded pre-hospital.

Abdominal pain

IMP // Abdominal pain of unclear aetiology, currently localised to right lower quadrant with guarding on examination. Patient clinically stable. Differential considerations include appendicitis, renal colic, and gastrointestinal pathology.

Falls / trauma

IMP // Mechanical fall with ongoing right hip and groin pain and inability to weight bear, raising concern for underlying bony injury. No evidence of head injury or neurological deficit. Patient currently stable.

Shortness of breath

IMP // Presentation most consistent with acute exacerbation of COPD, evidenced by increased work of breathing, wheeze, and reduced oxygen saturations. Patient responding to initial treatment but remains at risk of deterioration. Differential diagnoses include pneumonia and cardiac failure.

Stroke-like symptoms

IMP // Acute onset left-sided weakness and speech disturbance consistent with suspected CVA. FAST positive. Symptom onset within thrombolysis window. Patient haemodynamically stable at present.

Mental health crisis

IMP // Acute mental health crisis with expressed suicidal ideation and reduced coping strategies. Patient currently calm but ongoing risk to self identified. Requires urgent mental health assessment.

Example (uncertainty acknowledged)

IMP // Cause of collapse unclear at this stage. Patient reports prodromal dizziness with brief LOC. Observations currently stable. Differential considerations include vasovagal episode, cardiac arrhythmia, and seizure activity.

One-line IMP (when space is tight)

• IMP // Suspected ACS — haemodynamically stable

• IMP // Mechanical fall with possible hip injury

• IMP // SOB likely COPD exacerbation; pneumonia not excluded

• IMP // Cause of symptoms unclear; requires further investigation

The plan should clearly describe:

• What options were discussed

• What decision was made and why

• What actions were taken

• What was not done and why

• What happens next

Avoid vague statements like “plan discussed” without detail.

Gold-standard PLAN structure

PLAN // Assessment findings and differential diagnoses discussed with patient (and carers where appropriate). Decision made to [convey / manage at home / refer] based on [clinical findings, observations, risk assessment, patient preference]. [Treatments/interventions] provided in line with guidance. [Advice/referrals] arranged. [Transport / position / pre-alert] completed as required.

Example PLAN narratives (ready to paste)

Conveyance to ED

PLAN // Findings discussed with patient. Given ongoing chest pain and cardiac risk factors, decision made to convey to ED for further investigation. Aspirin administered and oxygen therapy initiated. Pre-alert made to receiving ED. Patient conveyed supine on trolley. Care handed over to ED staff on arrival.

Home management with GP follow-up

PLAN // Assessment findings discussed. Symptoms deemed suitable for home management at present. Safety-netting advice provided. Advised to contact own GP for urgent review and prescription if required. Patient happy with plan and verbalised understanding.

Referral to another service

PLAN // Assessment findings discussed with patient. Advice sought from GP/ANP regarding home management. Referral accepted for same-day review. Patient left at home with written and verbal advice.

Trauma / mobility issue

PLAN // Given inability to weight bear and ongoing hip pain, decision made to convey for imaging. Analgesia provided. Patient transferred using carry chair and conveyed semi-recumbent. ED pre-alerted.

Mental health crisis

PLAN // Risks discussed with patient. Given ongoing suicidal ideation, decision made for conveyance for urgent mental health assessment. Patient agreed to plan. Conveyed to ED with MH pre-alert.

Key elements to consider documenting

• Conditions discussed (including differentials)

• Home vs conveyance decision and rationale

• Advice sought (GP, ANP, clinical desk)

• Red flags explained

• Patient acceptance or refusal

• Method of extraction and transport position

• Use of other agencies

• Pre-alert made or not (and why)

• ETA and destination

• Accompanied by (and why)

• Didn’t do and clinical justification

Example “Didn’t do” documentation

• GTN not administered due to systolic BP <100 mmHg

• IV access not established as patient clinically stable and declined

• Analgesia declined by patient after discussion

One-line PLAN (when space is tight)

• PLAN // Convey to ED for further investigation; pre-alert made

• PLAN // Home management with GP follow-up and safety-netting

• PLAN // Referral accepted for same-day community review

Worsening advice must clearly show:

• What to watch for

• What action to take

• Who is responsible

• That the advice was understood

Avoid generic phrases without detail.

Gold-standard worsening advice structure

WORSENING ADVICE // Patient (and/or carer) advised to seek urgent medical help via 999 for [specific red flags], or to contact 111 / GP for [non-urgent concerns]. Follow-up pathway [arranged / advised]. Advice provided verbally and understood.

What to Monitor For (Examples – tailor to case)

Document specific symptoms, not vague “deterioration”.

Examples:

• Increasing pain or new pain

• Reduced level of consciousness or confusion

• Chest pain, shortness of breath, palpitations

• Persistent vomiting or inability to keep fluids down

• New weakness, speech or vision changes

• Fever, rigors, or signs of infection

• Bleeding, black stools, or vomiting blood

• Reduced urine output

Example Worsening Advice Narratives (Ready to Paste)

Standard home management

WORSENING ADVICE // Advised to call 999 if chest pain, shortness of breath, collapse, or reduced level of consciousness occurs. Advised to contact 111 or own GP if symptoms worsen or fail to improve. Patient verbalised understanding of advice.

With arranged follow-up

WORSENING ADVICE // Advised to seek urgent help via 999 for any deterioration including increasing pain, confusion, or collapse. GP follow-up arranged for same day review (ref: XXXX). Advised to attend appointment and follow medication instructions. Advice understood.

With carer present

WORSENING ADVICE // Worsening advice provided to patient and partner. Partner able to repeat back red-flag symptoms and actions required. Patient left in partner’s care.

Key Prompts to Always Document

• Specific red flags discussed (list them)

• What service to contact (999 / 111 / GP)

• Any pathway arranged (HCP call/visit + reference)

• Medication advice (including POM instructions)

• Who patient was left with

• Who repeated advice back

• Agreement on scene that plan was understood

• Other HCPs involved (e.g. GP, ANP, ED)

• Documents left (PRF copy, ECG, leaflets)

• Final observations recorded (3rd set if appropriate)

• Document / incident numbers (e.g. SB171282)

One-line Worsening Advice (when space is tight)

• WORSENING ADVICE // Red flags explained; pt able to repeat back; left with partner; GP review arranged

• WORSENING ADVICE // Advised 999 for deterioration, 111/GP if concerns; advice understood

Closing line (useful and defensible)

All persons on scene confirmed understanding of the plan and were happy with decisions made.

Refusal must demonstrate that the patient:

• Had capacity

• Understood the situation and risks

• Was able to weigh up options

• Made a voluntary decision

• Was given clear safety-netting

Avoid vague phrases like “patient refused” on their own.

Gold-standard refusal structure (CURE)

REFUSAL // Patient declined [assessment / treatment / conveyance] after discussion. Capacity confirmed at time of decision. Patient demonstrated understanding of their condition and the risks of refusing, and was able to repeat these risks back. Decision made voluntarily without coercion. Patient A&Ox4, not under the influence of alcohol or drugs. Worsening advice provided and understood.

Example refusal narratives (ready to paste)

Refusal of conveyance

REFUSAL // Pt declined conveyance to ED following assessment. Capacity confirmed. Pt understood concerns regarding chest pain and risks including deterioration and MI, and verbalised these risks back. Pt A&Ox4, calm, and not under influence of alcohol or drugs. Worsening advice given and understood. Pt left at home with partner.

Refusal of treatment

REFUSAL // Pt declined IV access and analgesia after explanation of benefits and risks. Capacity confirmed. Pt able to explain rationale for refusal and verbalised understanding of potential for ongoing pain and delayed recovery. Decision respected.

Partial refusal

REFUSAL // Pt consented to assessment but declined conveyance. Risks of remaining at home explained, including potential for deterioration. Pt demonstrated understanding and repeated risks back. Capacity intact at time of decision.

Refusal with safeguarding awareness

REFUSAL // Pt declined conveyance. Capacity confirmed. Risks explained and repeated back. Pt appeared fearful of hospital admission due to caring responsibilities. No immediate safeguarding concerns identified; however, advice given to contact services if situation changes.

Key prompts to document (don’t miss)

• What exactly was refused? (assessment / treatment / conveyance)

• Capacity confirmed at the time

• Patient’s understanding of risks

• Ability to repeat risks back in their own words

• Mental state (A&Ox4)

• Intoxication explicitly excluded

• Who else was present (family/carer)

• Worsening advice given and accepted

• Who agreed with the plan on scene

One-line refusal (when space is tight)

• REFUSAL // Pt declined conveyance. Capacity intact, risks explained and repeated back, A&Ox4, not intoxicated. Worsening advice given.

• REFUSAL // Pt declined IV access after discussion; capacity confirmed.

Safeguarding should document:

• That safeguarding was considered

• What type of risk was identified (or not)

• Who was affected

• What action was taken

• Who was informed

• Why any action was not taken

Avoid vague statements such as “no safeguarding concerns” without context.

Gold-standard safeguarding structure

SAFEGUARDING // Consideration given to safeguarding concerns including [categories]. [Concerns identified / no immediate concerns identified]. [Actions taken / rationale for no referral] documented. Relevant parties informed as appropriate.

Safeguarding Categories to Consider

Document consideration of the following where relevant:

• Physical abuse

• Domestic abuse

• Sexual abuse

• Psychological / emotional abuse

• Financial or material abuse

• Neglect / acts of omission

• Self-neglect

• Organisational abuse (care settings)

• Modern slavery / trafficking

• Mate crime

• Child safeguarding (if applicable)

Example Safeguarding Narratives (Ready to Paste)

No safeguarding concerns identified (but considered)

SAFEGUARDING // Safeguarding considered. No concerns identified following assessment. Patient appears well supported at home, able to meet own care needs, and no indicators of abuse, neglect, or coercion identified at time of attendance.

Adult safeguarding concern identified

SAFEGUARDING // Concerns identified regarding potential neglect due to poor living conditions and missed medications. Adult safeguarding referral completed and shared with local authority. Patient informed of referral. Details documented and conveyed to receiving team.

Domestic abuse consideration

SAFEGUARDING // Safeguarding considered. Patient seen alone. No disclosure of domestic abuse at this time. No physical indicators observed. Patient advised of support services and encouraged to seek help if circumstances change.

Child safeguarding concern

SAFEGUARDING // Child safeguarding concerns identified due to unexplained bruising and inconsistent history. Child Protection referral completed and police informed. Hospital safeguarding team notified on arrival.

Self-neglect

SAFEGUARDING // Concerns identified regarding self-neglect including poor hygiene, inadequate nutrition, and medication non-compliance. Adult safeguarding referral completed. Patient informed and agreed to referral.

Financial abuse

SAFEGUARDING // Concerns identified regarding possible financial abuse by family member, as reported by patient. Adult safeguarding referral completed. Patient requested referral and understood process.

Modern slavery / trafficking (considered)

SAFEGUARDING // Consideration given to modern slavery and trafficking. No indicators identified at this time.

When No Referral Is Made (Important)

If no referral is made, explain why:

SAFEGUARDING // Although concerns considered, threshold for safeguarding referral not met at this time. Patient has capacity, declined referral, and no immediate risk identified. Advice provided and details documented should concerns escalate.

Key Prompts (Don’t Miss)

• Who was spoken to alone (if appropriate)

• Who else was present

• Whether the patient was informed of referral

• Whether police / social services / hospital safeguarding team were notified

• Reference numbers (if available)

• Any advice or signposting provided

Relevant Legislation (Wales)

• Social Services and Well-being (Wales) Act 2014

• All Wales Child Protection Procedures

• Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015

• Serious Crime Act 2015

• Well-being of Future Generations (Wales) Act 2015

One-line safeguarding (when space is tight)

• SAFEGUARDING // Considered – no concerns identified

• SAFEGUARDING // Adult safeguarding referral completed re neglect

• SAFEGUARDING // CP concerns – referral completed and police informed

Mental health assessment should document:

• Current presentation

• Risk to self or others

• Capacity and insight

• Protective factors

• Decision-making and plan

Avoid vague phrases like “mental health issues” without context.

Core Mental Health Assessment

MH // Patient’s mental state assessed. Mood [low/anxious/elevated/appropriate]. Affect [congruent/incongruent]. Thought processes [logical/disordered]. Speech [normal/pressured/slurred]. No evidence of [hallucinations/delusions] reported or observed [if applicable].

• Patient says they feel low and looks tearful → congruent

• Patient says they’re fine but looks distressed or tearful → incongruent

Risk to Self or Others

Document explicitly.

Risk assessment considered:

• Suicidal ideation

• Self-harm thoughts or behaviours

• Risk to others

• Neglect / inability to care for self

Example:
MH // Pt reports passive thoughts of self-harm but denies active suicidal intent or plan. No immediate risk to others identified.

Suicide Risk (if relevant)

Use a recognised structure (see the. SAD PERSONS / AX tool) alongside clinical judgement.

Example:
MH // Suicide risk assessed using SAD PERSONS framework. Score [X]. Protective factors identified including [family support / future plans / engagement with services].

Capacity & Insight

Mental health presentations do not automatically remove capacity — document this clearly.

Example:
MH // Capacity assessed and deemed intact. Pt able to understand, retain, weigh information, and communicate decision. Insight into condition demonstrated.

Or if impaired:

MH // Capacity impaired due to acute mental health crisis. Pt unable to weigh information regarding risk. Decision made in best interests.

Protective Factors

Always document what is keeping the patient safe, if present.

Examples:

• Supportive family or carers present

• Engagement with MH services

• Willingness to seek help

• Absence of plan or intent

Example narrative:
MH // Protective factors include partner present, ongoing engagement with CMHT, and willingness to attend hospital.

Substance Use (if relevant)

MH // Alcohol/drug use [denied/reported]. Pt [not intoxicated / intoxicated] at time of assessment. Impact on capacity [none / present].

Safeguarding Interface

Mental health often overlaps with safeguarding — make the link explicit.

Example:
MH // No immediate safeguarding concerns identified. Adult safeguarding considered due to vulnerability.

PLAN (Mental Health)

Link assessment directly to outcome.

Conveyance

PLAN // Given ongoing suicidal ideation and impaired coping strategies, decision made to convey for urgent mental health assessment. Pt agreed to plan. MH pre-alert completed.

Home management

PLAN // No immediate risk identified. Pt declined conveyance but agreed to contact GP/CMHT. Safety-netting advice provided. Support person present.

Refusal

REFUSAL // Pt declined conveyance. Capacity intact. Risks explained and repeated back. Worsening advice provided.

One-line Mental Health (when space is tight)

• MH // Low mood, no active SI, capacity intact

• MH // Suicidal ideation present; SAD PERSONS score 7; conveyance arranged

• MH // Acute MH crisis, impaired capacity, best-interest conveyance

Mental Health Act — Quick Section Guide (UK)

Section 136

Police power.
Allows police to remove a person from a public place to a place of safety for mental health assessment if they appear mentally unwell and at risk.

Ambulance often asked to convey under S136.

Section 135

Police power for a private place (e.g. someone’s home).
Requires a warrant. Used to gain entry and remove a person to a place of safety.

Section 2

Hospital detention for assessment.
Up to 28 days.

Section 3

Hospital detention for treatment.
Up to 6 months (can be renewed).

Section 5(2)

Doctor’s holding power.
Allows a hospital doctor to temporarily stop a voluntary patient leaving (up to 72 hours).

Section 5(4)

Nurse’s holding power.
Short-term hold (up to 6 hours) until a doctor arrives.

Section 17

Leave from hospital (“section leave”).
Patient is detained but allowed out under conditions.

Section 117

Aftercare duty.
Support provided after discharge from Section 3 (and some others).

One-line memory aid

• 136 = police + public place

• 135 = police + private place

• 2 = assess

• 3 = treat

• 5 = stop leaving hospital

• 17 = leave

• 117 = aftercare

Score 1 point for each factor present.

• S — Sex (male)

• A — Age (<19 or >45)

• D — Depression

• P — Previous attempt

• E — Ethanol

• R — Rational thinking loss

• S — Social supports lacking

• O — Organised plan

• N — No partner

• S — Sickness

Outcome guide

• 0–2: Home with appropriate follow-up

• 3–6: Admit or discharge with appropriate follow-up

• 7–10: Admit to hospital

Use alongside clinical judgement.

Where a patient is currently serving or a military veteran, this should be documented, as prior service may be relevant to:

• Mental health (e.g. PTSD, moral injury)

• Physical injury or chronic pain

• Substance misuse

• Social isolation, housing, or employment difficulties

Where appropriate, patients (or families) should be signposted to specialist Armed Forces and veteran support services.

Veteran Support & Signposting (Examples)

• The Royal British Legion – Welfare, financial support, advocacy, and community services

• SSAFA – Practical, emotional, and financial support for serving personnel, veterans, and families

• Help for Heroes – Recovery support for wounded, injured, and sick veterans

• Combat Stress – Specialist mental health support for veterans

• Veterans UK – Pensions, compensation, and welfare support

• RFEA – The Forces Employment Charity – Employment and career support for service leavers and veterans

• Poppy Scotland – Veteran welfare and housing support (Scotland)

• Veterans’ Gateway – Single point of access to veteran support services

• Armed Forces Covenant – Ensures fair access to services for armed forces community

• The Soldiers’ Charity – Lifetime support for soldiers and their families

• RAF Benevolent Fund – Financial, practical, and emotional support for RAF community

• Royal Navy & Royal Marines Charity – Support for naval service personnel and families

Example Narrative (Good Practice)

ARMED FORCES // Pt disclosed previous service in the Armed Forces. Consideration given to potential service-related physical and mental health needs. Veteran support services discussed and signposted where appropriate.

Written to withstand coronial, legal, and governance scrutiny.

Purpose

This section must clearly demonstrate:

• Who the patient is

• Where and how they were found

• What was assessed

• How long assessment occurred

• Why resuscitation was not commenced / was discontinued

• Who was informed and when

Avoid assumptions. Be factual. Be chronological.

1) Patient Identification

Document how identity was confirmed.

Example:

IDENTITY // Identity confirmed via photo ID / relative confirmation / care home records / police confirmation. Name and DOB verified.

If identity unknown:

IDENTITY // Identity unknown at time of assessment. Police informed.

2) Location & Circumstances Found

This answers “What was the context of death?”

Include:

• Location (home, care setting, public place)

• Position of patient

• Who found the patient

• Time last seen alive (if known)

Example:

FOUND // Pt found supine in bed at home address by spouse at approx 0630 hrs. Last seen alive at approx 2200 hrs previous evening.

3) Initial Assessment on Arrival

Demonstrate that death was not assumed.

Example:

INITIAL ASSESSMENT // On arrival, pt unresponsive. No signs of life observed. No spontaneous breathing noted. No palpable central pulse.

4) Confirmation of Death — Clinical Examination

This is critical. Be explicit.

Document absence of all signs of life and duration of observation.

Gold-standard wording:

CONFIRMATION OF DEATH //
Pt assessed for signs of life.
• No spontaneous respirations observed
• No palpable central (carotid) pulse
• No heart sounds on auscultation
• No breath sounds on auscultation
• Pupils fixed and non-reactive
Pt observed continuously for ≥5 minutes with no return of cardiorespiratory activity.

(If local policy specifies a different duration, use that.)

5) Conditions Unequivocally Associated with Death (If Present)

These justify non-initiation of resuscitation.

Document only what you actually observe.

Examples (use only those present):

• Rigor mortis present

• Hypostasis (dependent lividity) present and fixed

• Decomposition / putrefaction evident

• Decapitation

• Hemicorporectomy

• Massive cranial or cerebral destruction incompatible with life

• Incineration

• Fetal maceration

Example narrative:

UNEQUIVOCAL SIGNS // Rigor mortis present to jaw and upper limbs. Hypostasis noted posteriorly and fixed. Injuries incompatible with life observed.

6) Resuscitation Decision

This is where coroners look closely.

Be clear why resuscitation was not started or was discontinued.

Not commenced

RESUSCITATION DECISION // Resuscitation not commenced due to presence of unequivocal signs of death as documented above, in line with current guidance.

Discontinued

RESUSCITATION DECISION // Resuscitation commenced prior to crew arrival / by crew and discontinued after [X] minutes due to [reasons], following confirmation of death.

7) Time of Death

Be precise.

TIME OF DEATH // Death confirmed at [HH:MM] on [date] by [clinician role].

If death occurred prior to arrival:

TIME OF DEATH // Life extinct on arrival. Death confirmed at [time].

8) DNACPR / Advance Decisions (If Applicable)

Always document whether this was checked.

ADVANCE DECISIONS // DNACPR form present and valid / not present / unable to locate at time of assessment. Advance decisions discussed with family where appropriate.

9) Notifications & Handover

Coroners expect to see who was told.

Document:

• Family informed

• Police notified (if required)

• GP / OOH / care provider notified

• Care home staff informed

Example:

NOTIFICATIONS // Death explained to spouse in clear and sensitive manner. Police informed due to sudden death at home. GP notified via OOH service. Scene left in care of police.

10) Property, Scene & Aftercare

Shows professionalism and completeness.

AFTERCARE // Pt left in situ. Property secured. Family offered time with deceased. Information provided regarding next steps. No immediate concerns raised.

11) Example Full Narrative (Gold Standard)

DEATH CONFIRMATION SUMMARY //
Identity confirmed via spouse. Pt found supine in bed at home address, last seen alive approx 2200 hrs. On arrival pt unresponsive with no signs of life. No spontaneous respirations, no palpable central pulse, no heart or breath sounds on auscultation, pupils fixed and non-reactive. Pt observed continuously for ≥5 minutes with no cardiorespiratory activity. Rigor mortis present with fixed hypostasis posteriorly. Resuscitation not commenced due to unequivocal signs of death. Death confirmed at 0712 hrs. DNACPR not present. Death explained to spouse. Police and GP notified. Pt left in care of police.

12) Common Coroner Questions This Covers

This section explicitly answers:

• How was death confirmed?

• How long was the patient observed?

• Why was resuscitation not attempted?

• Who confirmed death and when?

• Were advance decisions considered?

• Who was informed?

• What was the context of death?