11 Nov 2022 Derek Shaw · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2
Insufficient local NHS Trust capacity affecting ambulance attendance View source Delays in ambulance attendance View source
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 the delivery plan for recovering urgent and emergency care services.
View source
Department of Health and Social Care
Provide additional funding to expand ambulance capacity and improve response times.
View source
Department of Health and Social Care
Maintain the additional ambulance capacity funded for 2024/25.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source See 1 more action
×
AI-generated summary
Derek Shaw · 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
Derek Shaw fell at home and became unwell the following morning, but an ambulance was delayed and he suffered a cardiac arrest before the crew arrived. The inquest heard that earlier ambulance attendance was likely to have meant he would not have died, and that ambulance availability was affected by a complex capacity problem involving local NHS trusts.
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 local NHS Trust capacity affecting ambulance attendance
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves .
” Source location Derek Shaw · 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 attendance
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did .
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves.
” Source location Derek Shaw · 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 “As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025 and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf” Source location Response from Department of Health and Social Care
Open published response
×
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 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 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 Maintain the additional ambulance capacity funded for 2024/25.
Verbatim wording from the response “Your report highlights that EEAST 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
×
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 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
4 Nov 2022 Ellen Lillian MacFarlane · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance response caused by insufficient ambulance crews and vehicles 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. 6
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 additional funding to expand ambulance capacity and improve response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles to increase ambulance capacity.
View source
Department of Health and Social Care
Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.
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
Continue working with NHS England to reduce ambulance waiting and response times.
View source See 3 more actions
×
AI-generated summary
Ellen Lillian MacFarlane · 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
Ellen Lillian MacFarlane had an accidental fall at her care home and waited over five hours for an ambulance before being taken to hospital, where she was found to have a fractured neck of femur. She underwent surgery, subsequently deteriorated, and died at Tameside General Hospital. The concerns included delays in ambulance provision and difficulties obtaining cardiac tests at weekends, contributing to delays in deciding when to operate on fractured neck of femur patients.
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 caused by insufficient ambulance crews and vehicles
Wider context from the report “1. The inquest heard evidence that notwithstanding her age and frailty Ellen MacFarlane had to wait over 5 hours for an ambulance . This was due to the demands on the North West Ambulance Service on the day in question. The inquest heard that such delays were not unusual and were still occurring . The reason for the delay was a shortage of ambulance crews/vehicles due to a combination of high demand, staffing shortages and delays at ED ;
” Source location Ellen Lillian MacFarlane · 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 “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” 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 additional funding to expand ambulance capacity and improve response times.
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
×
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 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the additional ambulance capacity funded for 2023/24 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
×
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 support future demand.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to reduce ambulance waiting and response times.
Verbatim wording from the response “However, I recognise there is still more to do to reduce waiting/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
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 Ambulance performance is reviewed through the existing Strategic Partnership and Transformation Board.
Verbatim wording from the response “Your report raises concerns about ambulance response times by North West Ambulance Service NHS Trust (NWAS) and access to hospital services. In preparing this response, Departmental officials have made enquiries with NHS England. I have been reassured by NWAS that ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region and I am pleased to note performance by NWAS has improved since this sad case.” Source location Response from Department of Health and Social Care
Open published response
7 Oct 2022 Barbara HOLLIS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Unavailability of emergency ambulances during periods of high service demand View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
East of England Ambulance Service NHS Trust Spire Healthcare
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
Spire Healthcare
Establish a clinician escalation process for delayed inter-facility transfers, including clinical review, CAD documentation, prioritisation decisions and communication with requesting clinicians.
View source
Spire Healthcare
Continue considering options to improve timely patient transfers, including liaison with private ambulance providers and national-level solution development.
View source
East of England Ambulance Service NHS Trust
Maintain the Norfolk D1 system call place with stakeholders to discuss lengthy hospital handover delays and interim measures.
View source
East of England Ambulance Service NHS Trust
Operate the Category 1 drop-and-go process so crews waiting at hospital can respond to Category 1 calls immediately.
View source
East of England Ambulance Service NHS Trust
Operate the Category 2 rapid-release programme to enable eligible crews to hand over patients within 10 minutes and respond to Category 2 calls.
View source
East of England Ambulance Service NHS Trust
Continue regular executive-level escalation to address worsening hospital handover delays.
View source
East of England Ambulance Service NHS Trust
Review the current delay action plan.
View source See 4 more actions
×
AI-generated summary
Barbara HOLLIS · 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
Barbara Hollis underwent a total left knee replacement and became restless, confused and progressively unwell afterwards. Although an ambulance was requested urgently for transfer to a high dependency unit, the agreed transfer pathway was not followed and attendance was delayed; she died in the early hours of 23 February 2022. The concern was that emergency ambulance availability and response delays could result in future deaths while remedial steps were being assessed.
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 emergency ambulances during periods of high service demand
Wider context from the report “4. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service
5. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients . However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur
” Source location Barbara HOLLIS · 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 Establish a clinician escalation process for delayed inter-facility transfers, including clinical review, CAD documentation, prioritisation decisions and communication with requesting clinicians.
Verbatim wording from the response “I met with ████████, Patient Safety Officer (EEAST) and ████████, Control Room Lead (EEAST) on the 13th October 2022 to discuss options to improve ambulance response times for inter-provider transfers. We discussed the pressure facing the ambulance service at this time in great detail and ████████ took the time to explain that it would not be possible to provide any assurance regarding ambulance response times or to agree an early notification or booking service as you had suggested, due to the requirement to manage demand through the existing triage and prioritisation system. However, we did acknowledge that the ability to have a clinician to clinician discussion, where Spire senior nursing or medical staff can speak to a clinical lead within EEAST would enable detailed information to be provided regarding the rationale for transfer and patient condition.” Source location Response from Spire Norwich Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue considering options to improve timely patient transfers, including liaison with private ambulance providers and national-level solution development.
Verbatim wording from the response “We continue to consider other options to support timely transfer of patients, including liaison with private ambulance providers. The challenges with ambulance transfer delays have been reported to Spire Healthcare’s Executive committee and we are being supported to seek solutions to this challenge at a national level.” Source location Response from Spire Norwich Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the Norfolk D1 system call place with stakeholders to discuss lengthy hospital handover delays and interim measures.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Operate the Category 1 drop-and-go process so crews waiting at hospital can respond to Category 1 calls immediately.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Operate the Category 2 rapid-release programme to enable eligible crews to hand over patients within 10 minutes and respond to Category 2 calls.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. D1 system call place has been between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interims where that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Continue regular executive-level escalation to address worsening hospital handover delays.
Verbatim wording from the response “To highlight the nature of the handover delays, last month we lost 6295 hours of ambulance time outside hospitals in Norfolk waiting to handover, after the 15-minute handover period (i.e., not including that time). This does not account for the hours spent ‘cohorting’ patients, nor the lost manager time supporting this. This can be seen the effect on our C2 response time is hugely significant and correlates directly with delayed handovers. Escalations continue to take place regularly at executive level to try and ease this situation, but the trend nevertheless is still currently worsening.” 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 Review the current delay action plan.
Verbatim wording from the response “The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns. I have attached our current delay action plan that has recently been reviewed.” Source location Response from East of England Ambulance Service
Open published response
5 Oct 2022 Charles Stephen Rothwell · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure to match ambulance response capacity to demand View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Charles Stephen Rothwell · 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
Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.
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 match ambulance response capacity to demand
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains , such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got .”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes , Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h .
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care.
” Source location Charles Stephen Rothwell · 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 Continue lobbying national bodies for changes to reduce hospital handover delays and improve ambulance capacity.
Verbatim wording from the response “This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem.” Source location Response from Association of Ambulance Chief Executives
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 System-wide causes of ambulance delays must be addressed nationally by NHS England, the Department of Health and Social Care, and the wider health system.
Verbatim wording from the response “As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.” Source location Response from Association of Ambulance Chief Executives
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 National demand-and-capacity modelling is to be led by NHS England rather than undertaken by the organisation.
Verbatim wording from the response “The second issue in play here is that we believe that ambulance services no longer have the required capacity nationally to routinely deliver the nationally mandated response time targets even if the current handover delay issues were eliminated. This is due to an inexorable rise in demand for our services and an increasing level of acuity in terms of the calls being received. AACE has flagged this issue nationally repeatedly over the last few years and has called for a national piece of demand and capacity modelling across the sector led by NHSE. I am pleased to say that this is now gaining traction and whilst in its early stages is being pursued by NHSE at the present time.” Source location Response from Association of Ambulance Chief Executives
Open published response
14 Sep 2022 Irene Annie Davies · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Unavailability of ambulances for urgent responses View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Irene Annie Davies · 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
Irene Annie Davies had multiple underlying health issues, including congestive cardiac failure and an infected nephrostomy associated with renal stones. After an accidental fall at home on 1 March 2022, she waited more than an hour for a Category 2 ambulance response, was taken to hospital, and was found unresponsive there on 2 March 2022. The substantive concerns included delays to renal stone surgery and delays in ambulance attendance due to service capacity and availability issues.
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 urgent responses
Wider context from the report “2. The evidence given to the Inquest was that after falling Mrs Davies needed an ambulance urgently - a Category 2 response. The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time . The Inquest heard evidence that there was an ongoing issue of ambulance availability .
” Source location Irene Annie Davies · 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 Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Verbatim wording from the response “As announced in the Autumn Statement, the government is investing an additional £3.3 billion in each of 2023-24 and 2024-25 to enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year, including plans to improve Category 2 ambulance response times to 30 minutes.” Source location Response from Department of Health and Social Care
Open published response
26 Aug 2022 Christina Avis RUSE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Insufficient emergency ambulance availability for timely patient response View source
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
EAST
Participate in daily system calls with hospitals and other stakeholders to address lengthy handover delays and interim measures.
View source
EAST
Operate the Category 1 drop-and-go process to release crews for Category 1 emergencies.
View source
EAST
Operate the Category 2 rapid-release programme to release crews within 10 minutes for validated Category 2 calls.
View source
EAST
Review the current delay action plan.
View source See 1 more action
×
AI-generated summary
Christina Avis RUSE · 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
Christina Avis RUSE underwent a total left hip replacement on 14 December 2021, deteriorated, and died on 15 December 2021 after transfer to hospital was required. The report raises concern about delays in ambulance availability and response during high demand, noting that future deaths may occur while measures to address the issue are assessed.
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 emergency ambulance availability for timely patient response
Wider context from the report “1.EEAST were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes.
2. There were no emergency ambulances available to assign to this call due to high call demand.
3. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours , by which time Mrs Ruse had deteriorated further and had been taken back into the FEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours.
It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients . However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.
” Source location Christina Avis RUSE · 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 Participate in daily system calls with hospitals and other stakeholders to address lengthy handover delays and interim measures.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. Daily system calls take place between EAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interim measures that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Operate the Category 1 drop-and-go process to release crews for Category 1 emergencies.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. Daily system calls take place between EAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interim measures that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Operate the Category 2 rapid-release programme to release crews within 10 minutes for validated Category 2 calls.
Verbatim wording from the response “At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. Daily system calls take place between EAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interim measures that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity.” 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 Review the current delay action plan.
Verbatim wording from the response “The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns. I have attached our current delay action plan that has recently been reviewed.” Source location Response from East of England Ambulance Service
Open published response
17 Jul 2022 Ronald Hartley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulance attendance and transport for patients requiring hospital care View source
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
Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
View source
Department of Health and Social Care
Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
View source
Department of Health and Social Care
Provide £20 million to upgrade the ambulance fleet.
View source
Department of Health and Social Care
Invest significantly in the ambulance workforce and support workforce.
View source See 1 more action
×
AI-generated summary
Ronald Hartley · 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
Ronald Hartley fell in his garden, fractured his neck of femur, underwent surgery, became increasingly frail, and died in hospital on 22 November 2021. His family reported being told that an ambulance would take approximately six hours to attend, so they transported him to hospital themselves, causing him significant pain and discomfort.
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 attendance and transport for patients requiring hospital care
Wider context from the report “The evidence to the Inquest from the family was that when they found Mr Hartley and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr Hartley to hospital . He had fallen in his garden in November. The family were faced with a choice of waiting with him for 6 hours when he clearly needed to be in hospital or transporting him to hospital themselves. Given his distress and their concerns about the impact of the prolonged wait on him they decided to transport him to hospital in their own vehicle. The Inquest was told that this was extremely difficult and caused significant pain and discomfort to Mr Hartley.
” Source location Ronald Hartley · 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 Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Verbatim wording from the response “The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it.” 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 Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” 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 £20 million to upgrade the ambulance fleet.
Verbatim wording from the response “During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet.” 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 Invest significantly in the ambulance workforce and support workforce.
Verbatim wording from the response “The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by over 40% since September 2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service.” Source location Response from Department of Health and Social Care
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 The NHS will set out detailed recovery plans to improve urgent and emergency care performance.
Verbatim wording from the response “This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.” Source location Response from Department of Health and Social Care
Open published response
24 Jun 2022 Grenville Wait · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to meet target ambulance response times View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
WILL QUINCE MP
Invest an additional £3.3 billion in ambulance and urgent emergency care services in 2023–24 and 2024–25.
View source
WILL QUINCE MP
Invest in the ambulance workforce, contributing to increased NHS ambulance and support staffing since April 2010.
View source
×
AI-generated summary
Grenville Wait · 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
Grenville Wait fell while shopping, sustained a fractured sternum, and was later found deeply unconscious at home. He died after an ambulance response that was incorrectly coded as category 2 and arrived around 70 minutes after the 999 call; the principal concern was that target ambulance response times were routinely not being met nationally.
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 target ambulance response times
Wider context from the report “1) Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken via its patient safety plan to manage and respond to demands on its service, it is a matter of concern that target response times are still routinely not being met nationally . By way of illustration, the court heard evidence that on 21st June 2021, the Trust’s average response time for a category 2 call was 50 minutes with the response time to 90% of all relevant incidents of 1 hour and 48 minutes.
” Source location Grenville Wait · 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 Invest an additional £3.3 billion in ambulance and urgent emergency care services in 2023–24 and 2024–25.
Verbatim wording from the response “A range of measures are in place to improve ambulance performance. This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will also set out detailed recovery plans in the new year, including plans to improve ambulance response times and improve A&E waiting times.” 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 Invest in the ambulance workforce, contributing to increased NHS ambulance and support staffing since April 2010.
Verbatim wording from the response “The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by almost 40% since April 2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service.” Source location Response from Department of Health and Social Care
Open published response
17 Jun 2022 Gwynne SAMUEL · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1
Delays in providing ambulances to patients assessed as serious Amber 2 cases 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
Welsh Ambulance Services NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Welsh Ambulance Services NHS Trust
Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
View source
Welsh Ambulance Services NHS Trust
Recruit and train additional staff to increase operational response capacity across Wales.
View source
Welsh Ambulance Services NHS Trust
Implement new demand-aligned rosters across Wales, incorporating the identified additional single-staffed-car capacity.
View source
Welsh Ambulance Services NHS Trust
Use shorter-term forecasting and quarterly performance reports to develop mitigating action plans when performance is forecast below requirements.
View source
Welsh Ambulance Services NHS Trust
Use cohorting crews to offload patients delayed outside hospitals, releasing frontline vehicles for waiting community calls.
View source
Welsh Ambulance Services NHS Trust
Maintain unrestricted voluntary overtime availability for operational and clinical staff.
View source
Welsh Ambulance Services NHS Trust
Operate the Clinical Safety Plan to dynamically prioritise patients with the most serious conditions when demand exceeds available resources.
View source
Welsh Ambulance Services NHS Trust
Operate the Operational Delivery Unit to monitor real-time performance inhibitors, maintain situational awareness and coordinate mitigation across the unscheduled-care system.
View source
Welsh Ambulance Services NHS Trust
Develop and submit the Transition Plan seeking investment and setting out internal efficiency and delivery-model changes.
View source See 6 more actions
×
AI-generated summary
Gwynne SAMUEL · 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
Gwynne Samuel, a 95-year-old man who lived alone, fell at home and waited approximately 12 hours for an ambulance before being taken to hospital. He developed an acute kidney injury attributed to the prolonged lie, which delayed hip surgery; he subsequently developed a chest infection and died from pneumonia. The principal concern was the ambulance response time for a patient categorised as Amber 2 and whether the clinical effects of a prolonged lie in an elderly person were adequately considered during categorisation.
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 providing ambulances to patients assessed as serious Amber 2 cases
Wider context from the report “GS was an elderly gentleman who had suffered a significant fall. The time it took for an ambulance to arrive and convey him to hospital contributed to his death insofar that the development of an acute kidney injury, which compromised his treatment and general condition, was caused by a long lie.
A report obtained from WAST indicated that GS had been categorised as an Amber 2, which I understand is an urgent clinical priority considered serious but not life threatening.
Whilst I accept that there was no evidence that GS was in immediate peril, it would appear that the clinical ramifications of an elderly person lying for a long period of time are not taken into account during the categorisation process.
Whilst I heard evidence, and understand, the pressures on the ambulance service during the pandemic and the inability to release emergency ambulances due to congestion in hospital emergency departments, the inability to provide an ambulance to a patient determined to be in a serious condition (Amber 2) for 12 hours , puts lives in danger and, as in this case, may contribute to their death.
” Source location Gwynne SAMUEL · 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 Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
Verbatim wording from the response “The Medical Prioritisation Dispatch System (MPDS) does not provide a determinant code based on age within Protocol 17 (falls) which would prevent a specific prioritisation change for elderly patients. The principal role of the Clinical Support Desk (CSD) Clinician is to provide additional clinical triage, advice and support to patients to ensure that they can access the most clinically appropriate care for their urgent and emergency healthcare needs, commonly known as Hear and Treat (H&T). In addition to this principal role, the CSD also undertake a range of other clinical functions in pursuance of maximising patient safety for those awaiting an emergency ambulance. This includes reviewing long waiting patients to maintain patient safety.” Source location Response from Welsh Ambulance Services
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 and train additional staff to increase operational response capacity across Wales.
Verbatim wording from the response “The ORH concluded that bridging the gap would require an investment of 263 staff on a full time equivalent (FTE) basis across Wales. The Emergency Ambulance Services Committee (EASC) agreed to invest in the Trust, over a two year period – 2020/21 and 2021/22, and close the “relief gap”, while it was agreed re-rostering would help improve the alignment and mix of resources allied to patient demand.” Source location Response from Welsh Ambulance Services
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 new demand-aligned rosters across Wales, incorporating the identified additional single-staffed-car capacity.
Verbatim wording from the response “In the same time period, the Trust agreed to take steps to reduce abstractions due to sickness absence, to increase ‘hear and treat’ rates (where patients are triaged and given advice rather than deploying an ambulance) to 10.2% and to implement new rosters across Wales.” Source location Response from Welsh Ambulance Services
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 Use shorter-term forecasting and quarterly performance reports to develop mitigating action plans when performance is forecast below requirements.
Verbatim wording from the response “Seasonal planning including forecasting
As well as utilising the services of ORH in longer term demand and capacity modelling, the Trust also commissions services from Optima who use simulation models which can predict output performance based on a range of input assumptions.” Source location Response from Welsh Ambulance Services
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 Use cohorting crews to offload patients delayed outside hospitals, releasing frontline vehicles for waiting community calls.
Verbatim wording from the response “To further mitigate the risk significant hospital delays are causing the service, cohorting crews provided by a private provider are being used to care for patients delayed outside Morriston and the Grange Hospitals while specific funding remains available.” Source location Response from Welsh Ambulance Services
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 unrestricted voluntary overtime availability for operational and clinical staff.
Verbatim wording from the response “Voluntary overtime remains available for all operational/clinical staff across the Trust without financial restriction and whilst uptake has reduced in recent months, largely as a result of the current workplace experience, we continue to see in excess of 5,000 hours per week being worked. Controls to restrict the overall spend on overtime may need to be introduced as the year proceeds should the financial position require it.” Source location Response from Welsh Ambulance Services
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 Operate the Clinical Safety Plan to dynamically prioritise patients with the most serious conditions when demand exceeds available resources.
Verbatim wording from the response “Clinical Safety Plan” Source location Response from Welsh Ambulance Services
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 Operate the Operational Delivery Unit to monitor real-time performance inhibitors, maintain situational awareness and coordinate mitigation across the unscheduled-care system.
Verbatim wording from the response “The Operational Delivery Unit (ODU) acts as a central hub providing coordination for the Welsh Unscheduled Care System with a link between the Trust, Welsh Government, and all the Health Boards through a system-wide view.” Source location Response from Welsh Ambulance Services
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 Develop and submit the Transition Plan seeking investment and setting out internal efficiency and delivery-model changes.
Verbatim wording from the response “The Trust is committed to doing all that it can to reduce clinical risk, improve patient care and outcomes, ensuring that patients get the right service, in the right place, every time. The data in support of this statement shows that there is much more to do, with some actions within the Trust’s control, and many which are outside of its control.” Source location Response from Welsh Ambulance Services
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 New rosters will initially retain a relief gap because commissioners have not provided additional resources for 2022/23.
Verbatim wording from the response “The four working parties have now concluded, and it is anticipated that the new rosters will be implemented between September and November 2022. As outlined above, by aligning rosters more closely with demand patterns, this will have the equivalent impact of an increase of 72 WTE.” Source location Response from Welsh Ambulance Services
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 The Trust cannot insist on discrete system actions; substantial resourcing and policy direction depend on Welsh Government and other system partners.
Verbatim wording from the response “While significant collaborative work continues to be undertaken on these issues, there is little that the ambulance service can fundamentally do to insist on discrete actions, beyond lobbying and highlighting the very significant patient safety concerns which arise, particularly from extended waits outside hospitals, which inevitably also result in excessive waits for those patients awaiting help in the community.” Source location Response from Welsh Ambulance Services
Open published response
16 Jun 2022 Lee Anthony CARUANA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Delays in handing over ambulance patients at hospitals View source
Linked responses
Birmingham and Solihull Integrated Care System NHS England WILL QUINCE MP
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
NHS England
Issue a joint national letter requiring systems to address risks from prolonged ambulance handover delays.
View source
NHS England
Hold follow-up meetings with care systems and require them to set out plans for tackling handover delays and sharing system-level risks.
View source
NHS England
Provide targeted and intensive support, including capital and revenue support where required, to trusts experiencing the greatest ambulance handover delays.
View source
NHS England
Develop a wider support programme for acute trusts to improve ambulance handover performance.
View source
NHS England
Work across Integrated Care Boards to determine the capacity required to support performance and how it can be delivered.
View source
NHS England
Issue national guidance on increasing urgent and emergency care capacity and operational resilience, including action on Category 2 response times and ambulance handover delays.
View source
WILL QUINCE MP
Continue exploring options to minimise hospital-discharge delays, including capacity for people needing ongoing non-acute care.
View source
Birmingham and Solihull Integrated Care System
Coordinate a system-wide programme with all partners to improve urgent and emergency care flow and reduce ambulance handover delays.
View source
Birmingham and Solihull Integrated Care System
Carry out a multi-stakeholder improvement event to achieve a further step change in urgent and emergency care delivery.
View source
Birmingham and Solihull Integrated Care System
Increase use of Same Day Emergency Care and introduce surgical assessment virtual wards to support safe early discharge.
View source
Birmingham and Solihull Integrated Care System
Commission additional community beds and ambulance support for complex discharges to improve bed availability and discharge flow.
View source
Birmingham and Solihull Integrated Care System
Develop and fund the Birmingham and Solihull virtual-ward plan to support early discharge, admission avoidance and reduced ambulance turnaround times.
View source See 9 more actions
×
AI-generated summary
Lee Anthony CARUANA · 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
Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.
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 handing over ambulance patients at hospitals
Wider context from the report “1. During the inquest, evidence was given on behalf of West Midlands Ambulance Service from Clinical Governance Lead ████████ and Trust Investigations Officer ████████ that at the time of Mr Caruana's death the Trust was experiencing unprecedented demand due to high call volume and delays in handing over patients to hospitals . At the time Mr Caruana was identified as needing an ambulance following a 999 call at 23:53 on the 6 October 2021, 71 of the Trusts 253 ambulance crews on duty were at hospital awaiting handover, the longest wait that day had been 7 hours and 45 minutes for a crew waiting at Birmingham Heartlands Hospital.
2. Since October 2021 the number of calls received has started to reduce to normal levels. However, the problem of paramedic crews being stuck at hospitals awaiting handover has increased . As an Investigations Officer ████████ said she is continuing to see incidents where ambulance attendance has been delayed because a crew was not available due to the number of crews waiting at hospital . Her evidence was that this is putting lives at risk.
3. ████████, Governance and Performance Manager at London Ambulance Service, gave evidence to the inquest as an independent expert. In the course of his evidence, he explained that the problem of ambulance crews being stuck awaiting handover is a national issue . Based on his anecdotal experience and observations the number of calls that a crew is able to attend to in a 12 hour shift has dropped by approximately 1/3 as a result of this issue.
4. The evidence from West Midlands Ambulance Service is that they have raised awareness of this issue locally, they have taken steps to free up ambulances (such as leaving multiple patients under the care of one paramedic crew at hospital to free up other crews to leave and diverting patients to other services where possible) and there is nothing further that they can do.
5. In the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life .
” Source location Lee Anthony CARUANA · 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 Issue a joint national letter requiring systems to address risks from prolonged ambulance handover delays.
Verbatim wording from the response “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.” Source location Response from NHS England
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 Hold follow-up meetings with care systems and require them to set out plans for tackling handover delays and sharing system-level risks.
Verbatim wording from the response “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.” Source location Response from NHS England
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 targeted and intensive support, including capital and revenue support where required, to trusts experiencing the greatest ambulance handover delays.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” Source location Response from NHS England
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 Develop a wider support programme for acute trusts to improve ambulance handover performance.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” Source location Response from NHS England
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 across Integrated Care Boards to determine the capacity required to support performance and how it can be delivered.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” Source location Response from NHS England
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 Issue national guidance on increasing urgent and emergency care capacity and operational resilience, including action on Category 2 response times and ambulance handover delays.
Verbatim wording from the response “In addition, NHSE set out the next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter, in a letter on 12 August 2022 (Appendix B). This again highlighted the need to target Category 2 response times and ambulance handover delays.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue exploring options to minimise hospital-discharge delays, including capacity for people needing ongoing non-acute care.
Verbatim wording from the response “To drive further progress and support regional and local system arrangements, the Department has established a national discharge taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow. We will continue exploring options that minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of care.” 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 Coordinate a system-wide programme with all partners to improve urgent and emergency care flow and reduce ambulance handover delays.
Verbatim wording from the response “Birmingham and Solihull (BSOL) are very focused on the major risk posed by delay in ambulance handover to the care of others within the system. A major piece of work was instigated in late 2021, involving all partners, to ensure efficiency of flow within required pathways. This remains a major priority for the newly formed Integrated Care Board (ICB).” Source location Response from NHS Birmingham and Soilhull
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 Carry out a multi-stakeholder improvement event to achieve a further step change in urgent and emergency care delivery.
Verbatim wording from the response “One of the major priorities of the newly formed ICB is an immediate commitment to production of a system wide Urgent and Emergency Care strategy involving all ICS stakeholders with a current two week multi-stakeholder improvement event to ensure a further step change in delivery. Governance arrangements have been further re-defined for strategic, tactical and operational interventions. This is in addition to an ongoing forensic focus, both within individual organisations and at system level, to ensure that flow through the relevant pathways with joined up, integrated working remains a high priority. This work is described in greater detail below.” Source location Response from NHS Birmingham and Soilhull
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 use of Same Day Emergency Care and introduce surgical assessment virtual wards to support safe early discharge.
Verbatim wording from the response “Same Day Emergency Care (SDEC)” Source location Response from NHS Birmingham and Soilhull
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 Commission additional community beds and ambulance support for complex discharges to improve bed availability and discharge flow.
Verbatim wording from the response “- Commissioned increase in community beds both within Birmingham Community Healthcare Trust and the independent sector to ensure bed availability is not a limiting factor to complex discharge from acute services. Close working with local authority colleagues with trusted assessor models has enabled efficiency in discharge both from acute sector beds and from community beds to final residential destination. This has also been aided by commissioning of additional ambulance support for complex discharge patients.” Source location Response from NHS Birmingham and Soilhull
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 Develop and fund the Birmingham and Solihull virtual-ward plan to support early discharge, admission avoidance and reduced ambulance turnaround times.
Verbatim wording from the response “Virtual wards” Source location Response from NHS Birmingham and Soilhull
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.