26 Jun 2023 Mark Steven Wright · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to respond to calls within target timeframes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care South East Coast Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Department of Health and Social Care
Publish the urgent and emergency care recovery plan.
View source
Department of Health and Social Care
Provide additional ambulance funding and maintain expanded ambulance capacity, including new ambulances and specialist mental health vehicles.
View source
Department of Health and Social Care
Deliver 5,000 additional staffed, permanent hospital beds backed by dedicated funding.
View source
Department of Health and Social Care
Maintain the hospital bed capacity uplift in 2024/25.
View source
Department of Health and Social Care
Scale up virtual ward capacity to more than 10,000 beds nationally.
View source
Department of Health and Social Care
Provide funding to support timely and effective discharge from hospital.
View source
Department of Health and Social Care
Increase the NHS ambulance and support workforce.
View source
Department of Health and Social Care
Boost the number of paramedics by up to 15,600 through the NHS Long Term Workforce Plan.
View source
South East Coast Ambulance Service NHS Foundation Trust
Continue working with local and national partners on programmes addressing functional demand and required clinical support.
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AI-generated summary
Mark Steven Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Steven Wright deliberately overdosed on prescribed quetiapine at home during the night of 14 June or early hours of 15 June 2022, and was pronounced deceased after an ambulance arrived. The report identifies delays in the ambulance response, including SECAMBS operating under Stage 4 of its Surge Management Plan, as a significant concern because demand exceeded available resources and calls could not be answered within target timeframes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond to calls within target timeframes
Wider context from the report “There is a risk of a future recurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” Source location Mark Steven Wright · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the urgent and emergency care recovery plan.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional ambulance funding and maintain expanded ambulance capacity, including new ambulances and specialist mental health vehicles.
Verbatim wording from the response “The report highlights that SECamb was under high demand at the time of the incident. A primary aim of our recovery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 additional staffed, permanent hospital beds backed by dedicated funding.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved over 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the hospital bed capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved over 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scale up virtual ward capacity to more than 10,000 beds nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved over 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding to support timely and effective discharge from hospital.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved over 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the NHS ambulance and support workforce.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Boost the number of paramedics by up to 15,600 through the NHS Long Term Workforce Plan.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with local and national partners on programmes addressing functional demand and required clinical support.
Verbatim wording from the response “Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
26 Jun 2023 Keith Nielsen · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Insufficient service resources for responding to calls within target timeframes View source
Linked responses
Department of Health and Social Care South East Coast Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Publish the urgent and emergency care recovery plan with targets for improving A&E and Category 2 ambulance response times.
View source
Department of Health and Social Care
Fund and maintain additional ambulance capacity, including new ambulances and specialist mental health vehicles, to improve response times.
View source
Department of Health and Social Care
Set out plans through the NHS Long Term Workforce Plan to increase paramedic numbers by up to 15,600.
View source
South East Coast Ambulance Service NHS Foundation Trust
Continue working with partners on local and national programmes addressing functional demand and clinical support.
View source
South East Coast Ambulance Service NHS Foundation Trust
Conduct a system-wide review with external stakeholders to develop a sustainable care delivery model for current and future public needs.
View source
South East Coast Ambulance Service NHS Foundation Trust
Adjust rota patterns to improve alignment with changing demand.
View source See 3 more actions
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AI-generated summary
Keith Nielsen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Keith Nielsen fell at home, sustained a head injury while taking Warfarin, and died in hospital on 23 March 2022. The concerns included the handling of his 999 call, including the no-send disposition despite his circumstances, and repeated operation of the ambulance service at Stage 4 of its Surge Management Plan, with demand exceeding available resources and responses not meeting target timeframes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient service resources for responding to calls within target timeframes
Wider context from the report “There is a risk of a future reoccurrence of the situation which arose on 21 March 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan , meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes .
” Source location Keith Nielsen · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the urgent and emergency care recovery plan with targets for improving A&E and Category 2 ambulance response times.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2304-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund and maintain additional ambulance capacity, including new ambulances and specialist mental health vehicles, to improve response times.
Verbatim wording from the response “The report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out plans through the NHS Long Term Workforce Plan to increase paramedic numbers by up to 15,600.
Verbatim wording from the response “Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with partners on local and national programmes addressing functional demand and clinical support.
Verbatim wording from the response “Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a system-wide review with external stakeholders to develop a sustainable care delivery model for current and future public needs.
Verbatim wording from the response “Whilst SECAmb will continue to focus attention to optimise performance within the current commissioned service, it is recognised that to deliver comprehensive and sustainable improvement a full system-wide review in conjunction with external stakeholders is required, which in turn will lead to a model of care delivery that addresses the current and future requirements of the public across Kent, Surrey, Sussex, and North-East Hampshire.” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adjust rota patterns to improve alignment with changing demand.
Verbatim wording from the response “challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand.” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Comprehensive and sustainable improvement requires system-wide review and solutions with external health and care stakeholders, rather than SECAmb acting alone.
Verbatim wording from the response “It is recognised that to support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across Integrated Care Systems (ICSs). With ICSs becoming legally established in July 2022, this has changed the way Health and Social Care providers work collaboratively and plan delivery of services to their populations, with an increasing focus on public health, improving performance against national and local requirements, and recognising the need for integrated strategies for key areas such as workforce (linked to the recently published NHS Long Term Workforce Plan).” Source location Response from South East Coast Ambulance Service NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.