PFD report

Matthew Luke FAULKNER · Prevention of Future Deaths report

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Issued 29 Mar 2018•Hertfordshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
23

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Insufficient EEAS resources for demand
  2. Delays in handover to hospital
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
  3. Unsustainable public demand on the EEAS
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.18

  1. Action

    Deploy Patient Safety Intervention Teams to emergency departments experiencing prolonged ambulance handover delays.

    Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
  2. Action

    Collaborate with acute-sector organisations and Clinical Commissioning Groups to resolve hospital handover delays.

    Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.
  3. Action

    Increase operational capacity by recruiting frontline staff and providing additional frontline vehicles.

    Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing ambulance-handover monitoring, escalation and capacity-management arrangements are considered adequate to address delays.

    Stated by Luton and Dunstable University HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient EEAS resources for demand

Wider context from the report

“(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them. (2) That the current position regarding demand outstripping available resources is not significantly different to that in May 2017. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in handover to hospital

Wider context from the report

“(4) That there are still significant delays on hand-over to hospital, exacerbating the lack of Ambulances being available to answer emergency calls. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unsustainable public demand on the EEAS

Wider context from the report

“(3) That the demands placed on the EEAS by the public are not sustainable. With, in the region of, only 60% of ambulance attendances resulting in admission to hospital for urgent care. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Deploy Patient Safety Intervention Teams to emergency departments experiencing prolonged ambulance handover delays.

Verbatim wording from the response

“The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter. These teams were deployed to emergency departments across the region where handover delays were continuing past 45 minutes, where no immediate resolution of the situation is apparent and patients are waiting for an ambulance response in the community. The aim was to minimise patient wait and maximise the availability of ambulances. The teams worked collaboratively with emergency department staff to maintain the safety of patients in the department along with ensuring awareness of those 999 patients who are waiting for a response. This scheme stayed in place until March 2018.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018

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

Collaborate with acute-sector organisations and Clinical Commissioning Groups to resolve hospital handover delays.

Verbatim wording from the response

“I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018

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 operational capacity by recruiting frontline staff and providing additional frontline vehicles.

Verbatim wording from the response

“In April 2017 NHS England and NHS Improvement commissioned an independent service review to provide recommendations on the Best Service Model, Pricing Review, Capacity and Demand Analysis and the Commissioning Contract/ model. This review was completed by Deloitte as Deloitte and ORH, a company specialising in operational modelling for emergency and health services. The findings were published on 11th May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand. This is now factored into our emergency operations contract which will see a 15% increase over the next two years. This funding will enable the Trust to increase its frontline patient facing staff by 330 full time equivalent by 2020/2021. I enclose a copy of the service review for your information.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 1 · response
Published 17 June 2018

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 Ambulance Response Programme standards, including revised call assessment and categorisation.

Verbatim wording from the response

“Whilst this independent service review was being undertaken, nationally all ambulance services made significant changes to the way we respond to our patients due to the implementation of the Ambulance Response Programme. The Trust commenced the implementation of these new standards on the 18 October 2017, which involved allowing call handlers more time to assess 999 calls to determine which patients required an immediate response; and changes to the call categorisation. The new system allows for early recognition of life threatening conditions and is designed to free up more vehicles and staff to respond to emergencies. I understand ████████, the Trust’s former Medical Director, wrote to you”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 1 · response
Published 17 June 2018

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 educating the public about appropriate use of the 999 service.

Verbatim wording from the response

“I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018

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

Explore innovative support for patients with complex needs and frequent falls-related calls.

Verbatim wording from the response

“I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018

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

Reconfigure ambulance handover using lean principles to remove non-essential tasks and reduce handover times.

Verbatim wording from the response

“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”

Source location

2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 17 June 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct a June 2018 focus week using the previous improvement methods to restore ambulance handover performance.

Verbatim wording from the response

“We are conducting a focus week in June 2018, mirroring the methods we used to improve the situation last year, in order to bring performance back to the same levels as in April 2017. Having achieved the improvements required, the performance will be monitored on a weekly basis and focus weeks conducted if performance slips.”

Source location

2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 2 · response
Published 17 June 2018

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

Monitor ambulance handover performance weekly after implementing the improvements.

Verbatim wording from the response

“We are conducting a focus week in June 2018, mirroring the methods we used to improve the situation last year, in order to bring performance back to the same levels as in April 2017. Having achieved the improvements required, the performance will be monitored on a weekly basis and focus weeks conducted if performance slips.”

Source location

2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 2 · response
Published 17 June 2018

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

Board patients on wards by transferring them before beds become available, temporarily increasing ward capacity.

Verbatim wording from the response

“We will transfer patients to wards where beds will shortly become available even if the space has not yet become”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018

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

Transfer existing emergency-department patients into hospital and assessment beds to prioritise cubicle space for arriving ambulance patients.

Verbatim wording from the response

“It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018

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

Open further contingency areas as necessary to proactively create emergency-department capacity and reduce ambulance offload delays.

Verbatim wording from the response

“It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018

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 contingency capacity by operating an additional ward and surgical outlier bays to mitigate emergency-department overcrowding and ambulance offload delays.

Verbatim wording from the response

“On 30th May 2017, between 17:00 and 22:00 hours, 19 ambulances were delayed at the Luton and Dunstable Hospital. This consisted of 11 ambulances under 30 mins and 8 ambulances under 60 mins, amounting to 368 minutes in total. As it was the Tuesday post Bank Holiday, ED attendances were expected to be high and indeed 326 patients attended across the 24 hour period, higher than the rolling 30 day average of 296. 88 patients arrived by ambulance which is within normal daily expectations. The bed reports from that day indicates high numbers of patients in the department - at 4pm there were 67 patients in ED and 8pm, 58 patients, which would have caused some overcrowding within the department. Similarly due to the Bank holiday weekend, discharges were reduced compared with normal; the Trust already had taken steps to mitigate this by using one contingency ward of”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 17 June 2018

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 monitoring whether process improvements reduce emergency ambulance waiting times and positively affect patient care.

Verbatim wording from the response

“The Trust continues to work at improving the care provided to our patients and will continue to monitor that the improvements in our processes have made a positive impact and will continue to reduce the waiting times of emergency ambulances delivering patients.”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018

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

Assign a nurse and doctor responsibility for patients throughout the ambulance arrival and handover process.

Verbatim wording from the response

“• Improvements to Ambulance handover”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018

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

Introduce and operate the streaming process to reduce ambulance offloading delays.

Verbatim wording from the response

“The Trust are committed to ensuring that delays in offloading patients from ambulances are both minimised and escalated in a timely manner. I can assure you that the Medicine Health Care Group have introduced a number of process to prevent delays, these include”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018

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 an allocated paramedic to continuously monitor patients in the ambulance queue area and escalate concerns.

Verbatim wording from the response

“Whilst every effort is made to ensure that patients receive their initial assessment within 15 minutes, there are at times of peak demand, or when a number of ambulances arrive at the same time, patients who may have to wait in the designated ambulance queue area which is integral to the ED. There is a clear escalation process which staff will follow should there be an issue with queuing ambulances or a delay in ambulance handover of greater than 30 minutes. Our staff will initiate the ambulance handover escalation process and the priority will be given to the patient who requires the most urgent attention. In addition between the hours of 07.30 and 02.30 this area is further supported by an allocated Paramedic whose role is to continuously monitor the patients in this area and escalate any concerns.”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018

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 an escalation process for ambulance queues or handover delays exceeding 30 minutes, prioritising patients requiring the most urgent attention.

Verbatim wording from the response

“Whilst every effort is made to ensure that patients receive their initial assessment within 15 minutes, there are at times of peak demand, or when a number of ambulances arrive at the same time, patients who may have to wait in the designated ambulance queue area which is integral to the ED. There is a clear escalation process which staff will follow should there be an issue with queuing ambulances or a delay in ambulance handover of greater than 30 minutes. Our staff will initiate the ambulance handover escalation process and the priority will be given to the patient who requires the most urgent attention. In addition between the hours of 07.30 and 02.30 this area is further supported by an allocated Paramedic whose role is to continuously monitor the patients in this area and escalate any concerns.”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018

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

Existing ambulance-handover monitoring, escalation and capacity-management arrangements are considered adequate to address delays.

Verbatim wording from the response

“Generally the L&D’s performance regarding ambulance handovers is considered to be very reasonable. We have long adopted this metric as one of our triggers for patient flow escalation, which is monitored carefully throughout a 24 hour period. We always act upon handover delays if it becomes apparent that flow has reduced, and this is contained within our four times daily bed report. The escalation process involves input from an executive director and one of the medical directors. Whilst there is always room for improvement, the Weekly Sitrep ending 4th June 2017 shows that we had no ambulances waiting over 60 mins through the whole week. Attached to this letter is the East of England Ambulance service data for the period in question, showing the position of the L&D and all other trusts served by EEAST.”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Arrange a further briefing for HM coroners on the Trust’s actions.

    Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2018.
  2. 2

    Work collaboratively with health and social care providers to improve care coordination and patient safety across services.

    Stated by Luton and Dunstable University HospitalStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.
  3. 3

    Provide real-time data to Emergency Department staff to support timely escalation and resource redeployment.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
  4. 4

    Refurbish the Emergency Department and redesign its physical environment and care pathways.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
  5. 5

    Develop and refine consultant-led rapid patient assessment through PDSA improvement work and designed impact auditing.

    Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Cohorting ambulance patients is considered unsafe because they may be vulnerable and not yet clinically assessed.

    Stated by Luton and Dunstable University HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Arrange a further briefing for HM coroners on the Trust’s actions.

Verbatim wording from the response

“We are planning to arrange a further briefing for HM coroners in the coming months.”

Source location

2018-0097-Response-by-East-of-England-Ambulance-Service
Page 1 · response
Published 17 June 2018

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 collaboratively with health and social care providers to improve care coordination and patient safety across services.

Verbatim wording from the response

“All parts of the NHS are experiencing growing pressure with the increased demand in services and Luton and Dunstable Hospital are committed to working with all health and social care providers, as needed, to improve the quality of care and coordination between diverse services to ensure patients are kept safe.”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 17 June 2018

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 real-time data to Emergency Department staff to support timely escalation and resource redeployment.

Verbatim wording from the response

“Real time Data The Trust has implemented real time data, which is visibly available to all Emergency Department staff, allowing timely escalation of issues and redeployment of resources across the Emergency Department.”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018

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

Refurbish the Emergency Department and redesign its physical environment and care pathways.

Verbatim wording from the response

“Refurbishment of the Emergency Department- completed in December 2017 The Emergency Department (ED) team have actively worked to reshape and redesign the physical environment and pathways of care for our patients attending the department. The team have maintained a clear focus on improving a number of areas some of which include the following:”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018

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 refine consultant-led rapid patient assessment through PDSA improvement work and designed impact auditing.

Verbatim wording from the response

“• Rapid Assessment of patients (RAT)”

Source location

2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018

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

Cohorting ambulance patients is considered unsafe because they may be vulnerable and not yet clinically assessed.

Verbatim wording from the response

“We are aware that other Trusts have taken the decision to cohort patients while still on ambulance trolleys and still in the care of ambulance crews. This does nothing to resolve the release of ambulance crews and indeed removes more crews from attending to 999 calls. In response to this, EEAST created a Patient Safety Intervention Team (PSIT), consisting of 5 separate geographical teams each of between 3 and 6 clinical staff. These teams would be deployed into hospitals that had problematic ambulance offload problems, taking over the care of these patients while the hospital was unable to accommodate them and thus releasing the ambulance crew and vehicle back into active response duty. Although these PSIT teams were deployed on a daily basis to hospitals across Hertfordshire, they have never been sent to the L&D.”

Source location

2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026