Concerns raised 1
Systemic failure causing ambulance delays View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PATRICIA ANNE VAN DER EYKEN · 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
Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by preventing lifesaving treatment.
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 Systemic failure causing ambulance delays
Wider context from the report “1. Patricia’s death followed an ambulance delay, attributable to a systemic failure , which is likely to have contributed to Patricia’s death by preventing lifesaving treatment.
2. The systemic failure was found to be due to issues within healthcare services external to SWAST and notwithstanding increases in SWAST staff numbers and ambulance numbers.
” Source location PATRICIA ANNE VAN DER EYKEN · 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 Provide £200 million to ambulance trusts to expand capacity and improve ambulance response times.
Verbatim wording from the response “Your report highlights that SWAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
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 Specific actions to reduce handover delays and improve ambulance response times are best undertaken locally by SWAST and Royal Cornwall Hospital.
Verbatim wording from the response “Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) in particular how this impacted by handover delays and issues with discharging patients from hospital.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Failure to provide Category 2 ambulance responses within 40 minutes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jean WALKER · 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
Jean WALKER became unwell at home on 4 November 2022 and was struggling to breathe when her daughter called 999 at 0348. She died before the ambulance arrived at 0542 and was pronounced dead at 0551. The principal concerns were the delayed ambulance response and hospital offloading delays that reduced available ambulance resources; the inquest concluded that the delay resulted in a missed opportunity to provide medical assistance, although it could not be said that earlier intervention would have prevented her death.
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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 provide Category 2 ambulance responses within 40 minutes
Wider context from the report “(1) The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes . The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call .
” Source location Jean WALKER · 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 Provide additional funding to expand ambulance capacity and increase staffed hospital beds.
Verbatim wording from the response “Your report highlights reduced ambulance resource in the Yorkshire region at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from DHSC
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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 Participate with YAS and regional ICBs in joint priority-setting, performance improvement and additional investment allocation.
Verbatim wording from the response “Since April 2023, the three Integrated Care Boards (ICBs) across Yorkshire and Humber have worked jointly through an Executive Leadership Board (ELB) with YAS to agree joint priorities and to improve performance and allocate additional investment. This investment was aimed at recruiting additional ambulance crews, developing new ways of working to avoid conveyance to hospital, and investment in new vehicles, all of which are aimed at being able to provide a more timely response and meet increasing demand.” Source location Response from West Yorkshire ICB
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 West Yorkshire Integrated Care Board will respond on the specific local actions being taken to support ambulance response times.
Verbatim wording from the response “Your report raised concerns about ambulance response times and capacity at Yorkshire Ambulance Service NHS Trust (YAS) as a result of handover delays at hospitals. These concerns were also raised directly with the responsible NHS Integrated Care Board.” Source location Response from DHSC
Open published response
12 Mar 2024 Peter Beresford · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in paramedics attending Category 2 calls due to staff and emergency vehicle shortages View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department of Health and Social Care
Publish the delivery plan for recovering urgent and emergency care services.
View source
Department of Health and Social Care
Maintain additional ambulance capacity funded to expand capacity and improve response times during 2024/25.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Department of Health and Social Care
Increase ambulance workforce capacity through investment in NHS ambulance and support staff.
View source
Department of Health and Social Care
Boost paramedic numbers by up to 15,600 under the NHS Long Term Workforce Plan.
View source See 2 more actions
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AI-generated summary
Peter Beresford · 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
Peter Beresford contacted the North West Ambulance Service with chest pain on 25 September 2023 and was found deceased when an ambulance arrived at his home. The report raised concerns that delays in attending Category 2 calls persisted because of staff and emergency vehicle shortages, and that ambulance resources could not be fully utilised because of delays clearing Accident and Emergency departments.
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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 Delays in paramedics attending Category 2 calls due to staff and emergency vehicle shortages
Wider context from the report “(1) Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages .
” Source location Peter Beresford · 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 delivery plan for recovering urgent and emergency care services.
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 on average across this 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 Maintain additional ambulance capacity funded to expand capacity and improve response times during 2024/25.
Verbatim wording from the response “Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery 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 new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery 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 Increase ambulance workforce capacity through investment in NHS ambulance and support staff.
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
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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 Boost paramedic numbers by up to 15,600 under 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
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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 NWAS is best placed to respond on specific local actions to improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with NWAS who are best placed to respond on the specific actions being taken locally to improve ambulance response times. I note the measures the trust has said are being taken to improve performance, as set out in your report, including the ongoing recruitment of staff and also that performance regionally has been improving.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in getting ambulances to vulnerable patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jean Thomas · 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
Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.
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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 Delays in getting ambulances to vulnerable patients
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie . I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie . That pressure sore was exacerbated by a further long wait to be offloaded into hospital. The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes,
” Source location Jean Thomas · 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 Seek cross-government and health-system support to improve clinical risk management and release resources for community responses.
Verbatim wording from the response “The Trust also seeks to secure full support from Welsh Government, the wider NHS and local Government to ensure appropriate clinical risk management across the urgent and emergency care patient pathways to release resources to respond in the community.” Source location Response from Welsh Ambulance Services NHS Trust
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 Update dispatch codes to automatically deploy community volunteer and falls-response teams for patients on the ground over one hour.
Verbatim wording from the response “Secondly, I would like to share with you that the Trust has implemented a range of actions to mitigate as much as possible the effects of long community waits and the identification and mitigation of pressure damage. These include:” Source location Response from Welsh Ambulance Services NHS Trust
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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 Existing plans, resource measures and organisational monitoring are considered sufficient, so no further action is proposed on ambulance and hospital delays.
Verbatim wording from the response “Firstly at this time, the Trust does not propose to take any further action or new actions in relation to the matter of ambulance delays in arriving with patients and patients delayed outside of hospitals. The Trust is taking all possible steps within its control to ensure availability of appropriate resources.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
3 Feb 2024 Wyllow-Raine Swinburn · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Delays in ambulance or paramedic attendance View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
South Central 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. 8
South Central Ambulance Service NHS Foundation Trust
Refresh dispatch models to avoid unnecessary multiple-vehicle dispatches and review continued rapid-response-vehicle deployment.
View source
South Central Ambulance Service NHS Foundation Trust
Implement revised recruitment and retention plans to improve staffing numbers and placement of staff in appropriate posts.
View source
South Central Ambulance Service NHS Foundation Trust
Complete the rota review and implement the remaining new rotas.
View source
South Central Ambulance Service NHS Foundation Trust
Appoint a People Promise Manager and run exemplar programmes to improve frontline staff retention.
View source
South Central Ambulance Service NHS Foundation Trust
Increase paramedic apprenticeship numbers to expand the clinical workforce responding to patients.
View source
South Central Ambulance Service NHS Foundation Trust
Review ambulance-crew skill mix and dispatch clinical or non-clinical resources according to patient needs.
View source
South Central Ambulance Service NHS Foundation Trust
Implement the joint healthcare-partner process governing ambulance handover waiting times across all SCAS-area hospitals.
View source
South Central Ambulance Service NHS Foundation Trust
Update the vehicle fleet to improve reliability and reduce vehicles being unavailable or breaking down during operations.
View source See 5 more actions
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AI-generated summary
Wyllow-Raine Swinburn · 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
Wyllow-Raine Swinburn became unresponsive at home on 30 September 2022 after being discharged from hospital the previous evening, and died in hospital that day. The concerns related to a seven-minute delay in connecting the 999 call to an emergency call taker and the 31-minute response time for the first paramedic to attend.
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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 Delays in ambulance or paramedic attendance
Wider context from the report “The two concerns relate to, firstly, the length of time for the 999 call to be connected to a ECT (Emergency Call Taker, and secondly, the length of time for an ambulance/paramedic to attend . I fully appreciate there have been very significant demands on ambulance services including on SCAS in the past few years. I also understand, from the written and oral evidence of ████████ that multiple actions have been undertaken to improve ECT staffing and inconsistency. My primary concern is in relation to this first issue. I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times .
It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.
Given the risk associated with delayed response times , particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance.
” Source location Wyllow-Raine Swinburn · 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 Refresh dispatch models to avoid unnecessary multiple-vehicle dispatches and review continued rapid-response-vehicle deployment.
Verbatim wording from the response “• We are refreshing our dispatch models to ensure multiple vehicles are not dispatched to an incident to maintain resource availability. This refresh will include a review of the need for continued deployment of a rapid response vehicle when an ambulance arrives.” Source location Response from South Central Ambulance Service
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 Implement revised recruitment and retention plans to improve staffing numbers and placement of staff in appropriate posts.
Verbatim wording from the response “• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place.” Source location Response from South Central Ambulance Service
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 Complete the rota review and implement the remaining new rotas.
Verbatim wording from the response “• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place.” Source location Response from South Central Ambulance Service
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 Appoint a People Promise Manager and run exemplar programmes to improve frontline staff retention.
Verbatim wording from the response “• We appointed a People Promise Manager and started exemplar programmes to improve retention of frontline staff. Retention ensures that staff turnover is reduced, and we maintain a skilled workforce with knowledge and experience.” Source location Response from South Central Ambulance Service
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 Increase paramedic apprenticeship numbers to expand the clinical workforce responding to patients.
Verbatim wording from the response “• We increased our paramedic apprenticeship numbers to increase the number of clinical staff that can respond to patients.” Source location Response from South Central Ambulance Service
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 Review ambulance-crew skill mix and dispatch clinical or non-clinical resources according to patient needs.
Verbatim wording from the response “• We have reviewed the skill level of crews that are on our ambulances to ensure we have the appropriate skill mix on every resource depending on the incident they are being tasked to. We now have two types of resources, clinical and non-clinical, which are dispatched to patient’s dependent on their needs.” Source location Response from South Central Ambulance Service
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 Implement the joint healthcare-partner process governing ambulance handover waiting times across all SCAS-area hospitals.
Verbatim wording from the response “• The new joint process with our healthcare partners in relation to the amount of time an ambulance crew will wait at a hospital to handover their patient that was discussed at the inquest hearing has been successfully implemented with all hospitals within the SCAS geographical area. This has resulted in our Category 2 response times improving by 6 minutes to an average of 24 minutes in January and February 2025.” Source location Response from South Central Ambulance Service
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 Update the vehicle fleet to improve reliability and reduce vehicles being unavailable or breaking down during operations.
Verbatim wording from the response “• We are in the process of updating our fleet of vehicles to increase the reliability of our fleet and reduce occasions where vehicles are out of service or break down during operational use. A total of 124 new vehicles have been ordered, with 53 delivered by the end of 2024.” Source location Response from South Central Ambulance Service
Open published response
22 Jan 2024 Donna Georgina Smith · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 1
Failure to meet Category 2 ambulance response-time targets View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care North East 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. 19
Department of Health and Social Care
Publish a delivery plan for recovering urgent and emergency care services, including reducing Category 2 ambulance response times.
View source
Department of Health and Social Care
Expand and maintain ambulance capacity through additional funding to improve ambulance response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles to increase ambulance capacity.
View source
North East Ambulance Service NHS Foundation Trust
Continue delivering paramedic and Clinical Care Assistant recruitment plans to increase response capacity.
View source
North East Ambulance Service NHS Foundation Trust
Secure and use additional third-party hours funded by NHS England investment.
View source
North East Ambulance Service NHS Foundation Trust
Offer targeted overtime shifts to increase ambulance capacity.
View source
North East Ambulance Service NHS Foundation Trust
Establish bi-weekly fleet meetings to oversee vehicle shortages and improve vehicle availability.
View source
North East Ambulance Service NHS Foundation Trust
Implement the annual-leave buy-back scheme.
View source
North East Ambulance Service NHS Foundation Trust
Establish and progress a task-and-finish programme to release operational time and improve downtime management.
View source
North East Ambulance Service NHS Foundation Trust
Operate the centralised Operations Co-ordination Centre for time-critical operational matters.
View source
North East Ambulance Service NHS Foundation Trust
Implement handover escalation, navigation and liaison measures to mitigate ambulance handover delays.
View source
North East Ambulance Service NHS Foundation Trust
Implement a dedicated dispatcher and coordinate third-party resources for Pass to Patient Transport Service work.
View source
North East Ambulance Service NHS Foundation Trust
Improve Patient Transport Service staffing and resources for urgent, low-acuity and weekend demand.
View source
North East Ambulance Service NHS Foundation Trust
Review deployment guidance and responses per incident against national benchmarks.
View source
North East Ambulance Service NHS Foundation Trust
Review the end-of-shift tasking policy to identify opportunities to improve Category 2 response.
View source
North East Ambulance Service NHS Foundation Trust
Implement a one-division eVDI and daily-clean trial with standardised task timing and dispatch alerts.
View source
North East Ambulance Service NHS Foundation Trust
Implement staggered crew shifts and third-party bridging shifts to maintain capacity during transitions.
View source
North East Ambulance Service NHS Foundation Trust
Request additional commissioner funding for operational resources and Dispatch investment.
View source
North East Ambulance Service NHS Foundation Trust
Finalise the business case for commissioners to consider increased Dispatch resources.
View source See 16 more actions
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AI-generated summary
Donna Georgina Smith · 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
Donna Georgina Smith suffered chest pain at home on 17 July 2021, deteriorated into cardiac arrest, and died shortly after arriving at hospital. The report identifies concerns that her worsening condition was not recognised or escalated from Category 2 to Category 1, that the methods for detecting deterioration were not sufficiently robust, and that the ambulance response took one hour and six minutes.
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 Failure to meet Category 2 ambulance response-time targets
Wider context from the report “3. The category 2 call target (18minute average response and 95ᵗʰ percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call .
” Source location Donna Georgina Smith · 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 a delivery plan for recovering urgent and emergency care services, including reducing Category 2 ambulance response times.
Verbatim wording from the response “More broadly, as the Minister responsible for urgent and emergency care services, I recognise the pressures ambulance services are facing and the impact of waiting times for patients. Last January we published our Delivery plan for recovering urgent and emergency care services to” 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 Expand and maintain ambulance capacity through additional funding to improve ambulance response times.
Verbatim wording from the response “Your report highlights that NEAS were under high demand at the time of the incident. A primary aim of our Delivery 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 new ambulances and specialist mental health vehicles to increase ambulance capacity.
Verbatim wording from the response “Your report highlights that NEAS were under high demand at the time of the incident. A primary aim of our Delivery 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 Continue delivering paramedic and Clinical Care Assistant recruitment plans to increase response capacity.
Verbatim wording from the response “The actions to increase capacity update included:” Source location Response from North East Ambulance Service
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 Secure and use additional third-party hours funded by NHS England investment.
Verbatim wording from the response “• All additional third-party hours funded by additional NHS England investment have now been secured.” Source location Response from North East Ambulance Service
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 Offer targeted overtime shifts to increase ambulance capacity.
Verbatim wording from the response “• Additional shifts are being offered as overtime to boost capacity, with targeted overtime shifts incentivised over the Christmas period.” Source location Response from North East Ambulance Service
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 Establish bi-weekly fleet meetings to oversee vehicle shortages and improve vehicle availability.
Verbatim wording from the response “• Options to extend operating hours within NEASUS and support improved vehicle availability are being reviewed. Bi-weekly operational fleet meeting is now in place to provide clearer oversight and scrutiny to vehicle shortages to enable us to work better with NEASUS and be more proactive in identifying hot spots. (NEASUS is a wholly owned subsidiary of NEAS, providing fleet and other specialist services)” Source location Response from North East Ambulance Service
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 Implement the annual-leave buy-back scheme.
Verbatim wording from the response “• Buy-back scheme for annual leave has been implemented.” Source location Response from North East Ambulance Service
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 Establish and progress a task-and-finish programme to release operational time and improve downtime management.
Verbatim wording from the response “• Task and Finish group established to focus on releasing time including improvement of processes to manage downtime, system development being progressed to enable auto clear for crews. Individual level reports have been developed to support performance management of downtime. Changes to downtime codes and processes have been developed.” Source location Response from North East Ambulance Service
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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 Operate the centralised Operations Co-ordination Centre for time-critical operational matters.
Verbatim wording from the response “• Operations Co-ordination Centre (OCC) is now in place providing a centralised function based on the best practice and learning from other ambulance Trusts. A central point which will manage any time critical matters to ensure consistency and clarity to both internal and external stakeholders.” Source location Response from North East Ambulance Service
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 Implement handover escalation, navigation and liaison measures to mitigate ambulance handover delays.
Verbatim wording from the response “• The Trust continues to work with the ICB to support the wider system delivery of handover improvement. Additional system actions have been implemented to mitigate impact of handover times including: 2-hour handover reporting to Directors on-call, with 3-hour handovers escalated to ICB strategic on-call; Paramedic and Nurse Emergency Department navigators in place in 4 locations; Hospital Ambulance Liaison Officers (HALO) in place at James Cook. Development of immediate handover proposal is being progressed as part of C2 extremis actions.” Source location Response from North East Ambulance Service
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 Implement a dedicated dispatcher and coordinate third-party resources for Pass to Patient Transport Service work.
Verbatim wording from the response “1. Dedicated dispatch officer focused on pass to Patient Transport Service calls.” Source location Response from North East Ambulance Service
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 Improve Patient Transport Service staffing and resources for urgent, low-acuity and weekend demand.
Verbatim wording from the response “4. Secure additional Patient Transport Service (PTS) support focused on weekends.” Source location Response from North East Ambulance Service
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 Review deployment guidance and responses per incident against national benchmarks.
Verbatim wording from the response “3. Review Dispatch Plan on multiple resource assignments.” Source location Response from North East Ambulance Service
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 Review the end-of-shift tasking policy to identify opportunities to improve Category 2 response.
Verbatim wording from the response “7. Review End of Shift tasking.” Source location Response from North East Ambulance Service
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 Implement a one-division eVDI and daily-clean trial with standardised task timing and dispatch alerts.
Verbatim wording from the response “Ongoing work linked with the above includes the following improvements to help maintain resource availability for Category 2 emergency response. NEAS are currently employing the following additional tactics.” Source location Response from North East Ambulance Service
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 Implement staggered crew shifts and third-party bridging shifts to maintain capacity during transitions.
Verbatim wording from the response “Staggered shift start and finish times” Source location Response from North East Ambulance Service
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 Request additional commissioner funding for operational resources and Dispatch investment.
Verbatim wording from the response “On a more general note, the Trust is currently in contract negotiations in respect to funding from our commissioners. We have requested additional funding to enable an increase in resources to help improve service delivery, including improving ambulance response times. I am aware that the contract negotiations include discussions surrounding the wider health and social care system and what other partners can do to assist with easing pressures on the Trust. Factors such as hospital handover delays, availability of other services, demand deflection and inappropriate discharges all create potentially unnecessary demand on the Trust. This is not unique in our region and is a challenge faced by our colleagues in other ambulance services around the country.” Source location Response from North East Ambulance Service
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 Finalise the business case for commissioners to consider increased Dispatch resources.
Verbatim wording from the response “In addition to the pressures on our operational crews, the funding request is to help secure further investment into the Dispatch function to reduce the chance of missed opportunities to dispatch an ambulance to patients most in need. As demand for NEAS services has grown, increasing numbers of patients remain on the Dispatch Stack. With workloads on each Dispatch desk growing, NEAS commissioned independent reviews by the Association of Ambulance Chief Executives and Operational Research in Health (ORH). The evidence from these reviews shows that each Dispatch desk has more resources than would be considered appropriate to achieve optimum performance with the resources available. A business case is being finalised for commissioners to consider as part of the 2024/2025 planning rounds.” Source location Response from North East Ambulance Service
Open published response
×
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 Some planned improvements to ambulance response performance depend on securing additional funding through forthcoming negotiations.
Verbatim wording from the response “On a more general note, the Trust is currently in contract negotiations in respect to funding from our commissioners. We have requested additional funding to enable an increase in resources to help improve service delivery, including improving ambulance response times. I am aware that the contract negotiations include discussions surrounding the wider health and social care system and what other partners can do to assist with easing pressures on the Trust. Factors such as hospital handover delays, availability of other services, demand deflection and inappropriate discharges all create potentially unnecessary demand on the Trust. This is not unique in our region and is a challenge faced by our colleagues in other ambulance services around the country.” Source location Response from North East Ambulance Service
Open published response
15 Jan 2024 Dennis John William KING · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Unavailability of ambulances for timely urgent transfers and emergency call attendances View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England The 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. 17
Department of Health and Social Care
Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.
View source
Department of Health and Social Care
Provide £200 million of additional ambulance funding to expand capacity and improve response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective hospital discharge.
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
NHS England
Improve ambulance performance and response times across England.
View source
NHS England
Increase ambulance capacity by growing the workforce.
View source
NHS England
Speed up hospital discharges to support ambulance availability and urgent care flow.
View source
NHS England
Maintain and update the national framework for inter-facility ambulance transfers.
View source
The Trust
Recruit additional frontline clinicians to increase ambulance staffing, targeting more than 300 clinicians in place by March 2024.
View source
The Trust
Recruit additional control-room clinicians to expand clinical triage and enable safer transfers to alternative services.
View source
The Trust
Establish and operate the Suffolk Unscheduled Care Coordination Hub with healthcare partners to increase appropriate referrals and provide remote crew support.
View source
The Trust
Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
View source
The Trust
Work with local acute trusts to reduce hospital delays affecting ambulance availability.
View source
The Trust
Implement the Call before you convey programme with healthcare partners to support appropriate conveyance and pathway decisions.
View source
The Trust
Implement a same-day emergency care team at West Suffolk Hospital to direct patients to appropriate facilities and reduce emergency-department handover delays.
View source See 14 more actions
×
AI-generated summary
Dennis John William KING · 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
Dennis John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.
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 Unavailability of ambulances for timely urgent transfers and emergency call attendances
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” Source location Dennis John William KING · 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 Delivery Plan for Recovering Urgent and Emergency Care Services.
Verbatim wording from the response “I recognise the pressures our A&E and ambulance services are facing and the impact of waiting times for patients. That is why we published our ambitious Delivery Plan for Recovering Urgent and Emergency Care Services which aims to deliver sustained improvements in waiting times. The ambition is for 76% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2024, and to reduce Category 2 ambulance response times to 30 minutes on average this year.” 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 £200 million of additional ambulance funding to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of the delivery plan is to boost ambulance capacity. Ambulance services are receiving £200 million of additional funding this year to expand capacity and improve response times 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
×
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 new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of the delivery plan is to boost ambulance capacity. Ambulance services are receiving £200 million of additional funding this year to expand capacity and improve response times 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
×
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 £1.6 billion over two years to support timely and effective hospital discharge.
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 hospital’s patient flow and bed capacity. We have met our planned targets of delivering 5,000 more staffed, permanent hospital beds, supported by £1 billion of dedicated funding, and increased virtual ward bed capacity to over 10,000 ahead of winter. This builds on the £500 million used last winter and a further £1.6” 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 Improve ambulance performance and response times across England.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery Plan for Recovering Urgent and Emergency Care Services.” Source location Response from NHS 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 Increase ambulance capacity by growing the workforce.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times (specifically for Category 2 patients), increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS 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 Speed up hospital discharges to support ambulance availability and urgent care flow.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times (specifically for Category 2 patients), increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS 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 Maintain and update the national framework for inter-facility ambulance transfers.
Verbatim wording from the response “The National framework for inter-facility transfers was published by NHS England in July 2019 and updated in March 2021. The framework is intended for patients who require transfer by ambulance between facilities due to an increase in either their medical or nursing care need. The framework states that patients going directly to theatre for primary percutaneous coronary intervention should receive an IFT Level 2 (IFT2) Category 2 response and that the clinical staff responsible for the patient” Source location Response from NHS 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 Recruit additional frontline clinicians to increase ambulance staffing, targeting more than 300 clinicians in place by March 2024.
Verbatim wording from the response “• Additional recruitment with the aim for there to be over 300 more frontline clinicians in place by March 2024.” Source location Response from East of England Ambulance Service
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 Recruit additional control-room clinicians to expand clinical triage and enable safer transfers to alternative services.
Verbatim wording from the response “• Additional recruitment of clinicians within our control environment, allowing for greater volume of clinical triage to improve patient safety and to transfer patients to alternative services where appropriate. This is supported by the establishment of an Unscheduled Care Coordination Hub within Suffolk where we are working with the Integrated Care Board, the 111 provider and community services to increase referrals of appropriate patients to alternative services and to provide remote support to crews on scene.” Source location Response from East of England Ambulance Service
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 Establish and operate the Suffolk Unscheduled Care Coordination Hub with healthcare partners to increase appropriate referrals and provide remote crew support.
Verbatim wording from the response “• Additional recruitment of clinicians within our control environment, allowing for greater volume of clinical triage to improve patient safety and to transfer patients to alternative services where appropriate. This is supported by the establishment of an Unscheduled Care Coordination Hub within Suffolk where we are working with the Integrated Care Board, the 111 provider and community services to increase referrals of appropriate patients to alternative services and to provide remote support to crews on scene.” Source location Response from East of England Ambulance Service
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 Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
Verbatim wording from the response “• The implementation of our Operational Performance and Improvement Plan, which is our plan to improve our own efficiency as an organisation and to maximise ambulance availability. I attach a presentation on OPIP with this letter to provide an update on this work.” Source location Response from East of England Ambulance Service
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 Work with local acute trusts to reduce hospital delays affecting ambulance availability.
Verbatim wording from the response “Specifically in Suffolk, we have been engaging with the local Acute Trusts to reduce delays, which has started to have a positive effect on the number of our vehicles delayed at hospital. The Trust is also working with our ICB colleagues in Suffolk and across the region to implement the ‘Call before you convey’ programme. This allows frontline clinicians to speak with senior clinical advisors before making a decision on conveyance and check the most appropriate pathway for the patient is being followed. In the past month, the Trust has implemented the same-day emergency care team at West Suffolk Hospital to ensure patients are attending the right facility at the right time to avoid unnecessary handover delays in the Emergency Department.” Source location Response from East of England Ambulance Service
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 Implement the Call before you convey programme with healthcare partners to support appropriate conveyance and pathway decisions.
Verbatim wording from the response “Specifically in Suffolk, we have been engaging with the local Acute Trusts to reduce delays, which has started to have a positive effect on the number of our vehicles delayed at hospital. The Trust is also working with our ICB colleagues in Suffolk and across the region to implement the ‘Call before you convey’ programme. This allows frontline clinicians to speak with senior clinical advisors before making a decision on conveyance and check the most appropriate pathway for the patient is being followed. In the past month, the Trust has implemented the same-day emergency care team at West Suffolk Hospital to ensure patients are attending the right facility at the right time to avoid unnecessary handover delays in the Emergency Department.” Source location Response from East of England Ambulance Service
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 Implement a same-day emergency care team at West Suffolk Hospital to direct patients to appropriate facilities and reduce emergency-department handover delays.
Verbatim wording from the response “Specifically in Suffolk, we have been engaging with the local Acute Trusts to reduce delays, which has started to have a positive effect on the number of our vehicles delayed at hospital. The Trust is also working with our ICB colleagues in Suffolk and across the region to implement the ‘Call before you convey’ programme. This allows frontline clinicians to speak with senior clinical advisors before making a decision on conveyance and check the most appropriate pathway for the patient is being followed. In the past month, the Trust has implemented the same-day emergency care team at West Suffolk Hospital to ensure patients are attending the right facility at the right time to avoid unnecessary handover delays in the Emergency Department.” Source location Response from East of England Ambulance Service
Open published response
×
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 NHS England and the ambulance trust are responsible for responding to the report’s specific concerns within their respective remits.
Verbatim wording from the response “Your report raised concerns about ambulance response times, delays in transferring patients to specialist units within the East of England, the centralisation of services and the action plan provided by the local ambulance trust. I understand that NHS England (NHSE) has written to you to respond to those specific concerns within their remit as have East of England Ambulance Service Trust (EEAST) on action being taken locally. NHSE note in their response note if ambulances are not available immediately for patient transfers, the incident should be escalated to ensure an appropriate response.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in ambulance response times View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Shaun PARKS · 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
Shaun PARKS attended Doncaster Royal Infirmary with a heart attack and waited for an ambulance transfer to the Northern General Hospital. He deteriorated and died during a procedure on 13 December 2022. Concerns included a 3-hour 18-minute ambulance response delay, insufficient emergency dispatch staffing, and hospital delays in offloading patients that reduced ambulance availability.
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 Delays in ambulance response times
Wider context from the report “(1) The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.
” Source location Shaun PARKS · Prevention of Future Deaths report
Open source report
20 Dec 2023 James CAMPION · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2
Insufficient ambulance service capacity during periods of high demand View source Delays in ambulance dispatch View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Publish a delivery plan to recover urgent and emergency care services and improve waiting times.
View source
Department of Health and Social Care
Maintain additional ambulance capacity funded to expand availability and improve response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Department of Health and Social Care
Increase the ambulance workforce and plan to add up to 15,600 paramedics through the NHS Long Term Workforce Plan.
View source See 1 more action
×
AI-generated summary
James CAMPION · 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
James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.
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 ambulance service capacity during periods of high demand
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Source location James CAMPION · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance dispatch
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Source location James CAMPION · 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 a delivery plan to recover urgent and emergency care services and improve waiting times.
Verbatim wording from the response “The Department recognises 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 on average across this fiscal year. The plan is available at: 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
×
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 additional ambulance capacity funded to expand availability and improve response times.
Verbatim wording from the response “Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery 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
×
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 new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery 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
×
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 ambulance workforce and plan to add up to 15,600 paramedics through the NHS Long Term Workforce Plan.
Verbatim wording from the response “We have also 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
Concerns raised 1
Delays in ambulance responses to Category 2 calls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Department of Health and Social Care
Publish the delivery plan for recovering urgent and emergency care services.
View source
Department of Health and Social Care
Maintain additional ambulance capacity funded to improve response times during 2024/25.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Department of Health and Social Care
Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift in 2024/25.
View source
Department of Health and Social Care
Scale up national virtual ward capacity to more than 10,000 beds.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective hospital discharge.
View source
Department of Health and Social Care
Continue working with NHS England to reduce ambulance response times.
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David John Briggs · 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
David John Briggs died at the Northern General Hospital, Sheffield, on 15 November 2022 after developing urosepsis associated with urinary tract obstruction and a long-term catheter. His carers made several emergency calls as his breathing deteriorated, but the ambulance arrived at 0044 after the first call at 2049. Concerns included insufficient ambulance service resources, delays in responding to the Category 2 call, and hospital offloading delays that reduced ambulance availability.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance responses to Category 2 calls
Wider context from the report “(1) The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022.
” Source location David John Briggs · Prevention of Future Deaths report
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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 delivery plan for recovering urgent and emergency care services.
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 include reducing Category 2 ambulance response times to 30 minutes on average 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain additional ambulance capacity funded to improve response times during 2024/25.
Verbatim wording from the response “Your report highlights that YAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “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
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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 and maintain this 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 our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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
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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 national virtual ward capacity to more than 10,000 beds.
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 our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
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 our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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
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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 NHS England to reduce ambulance response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local action to improve ambulance response and patient handover times is assigned to South Yorkshire Integrated Care Board, as best placed to respond.
Verbatim wording from the response “Your report raised concerns about the capacity of Yorkshire Ambulance NHS Trust (YAS). You have appropriately shared your report and concerns with South Yorkshire Integrated Care Board, who are best placed to respond on the action being taken locally to improve ambulance response and patient handover times.” Source location Response from Department of Health and Social Care
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.