PFD report

Barbara Joan Howard · Prevention of Future Deaths report

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Issued 27 Nov 2017•West Sussex

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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

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 raised4

  1. Shortage of paramedic staff resulting in reduced ambulance availability
    Part of recurring concern: Insufficient ambulance service capacity for emergency calls
  2. Shortage of clinicians in the Emergency Operation Centre
    Part of recurring concern: Insufficient emergency control-room staffing capacityPart of recurring concern: Insufficient medical staffing capacity for timely patient care
  3. Failure to contact patients to ascertain call priority when response targets are missed
    Part of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires it
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.13

  1. Action

    Provide additional staff training to support the NHS Pathways audit function.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.
  2. Action

    Change call-volume forecasting and review rotas to align clinician capacity with demand.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2018.
  3. Action

    Introduce technology-based solutions to streamline the NHS Pathways audit process.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.

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

Shortage of paramedic staff resulting in reduced ambulance availability

Wider context from the report

“(1) In evidence the Court was informed that on 19 July 2017 the Chichester and Worthing areas had 30-40 staff vacancies made up of 2 Paramedic Practitioner roles and 25 paramedic roles. This equated to being 2 ambulances and 1 car short. I was advised that the current position is that the area is now 14 paramedics short which equates to 1 ambulance per day for the area. ”

Is this part of a recurring concern?

Yes — Insufficient ambulance service capacity for emergency calls.

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

Shortage of clinicians in the Emergency Operation Centre

Wider context from the report

“(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category. On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short. ”

Is this part of a recurring concern?

Yes — Insufficient emergency control-room staffing capacity; Insufficient medical staffing capacity for timely patient care.

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

Failure to contact patients to ascertain call priority when response targets are missed

Wider context from the report

“(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category. On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short. ”

Is this part of a recurring concern?

Yes — Failure to reliably telephone patients when follow-up or assessment requires it.

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

Failure to audit the required number of calls

Wider context from the report

“(3) The evidence was that SECAMB policy is that 1300 calls per month should be audited however the audit is only about 60% on target. ”

Is this part of a recurring concern?

Yes — Failure to reliably audit emergency call handling.

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

Provide additional staff training to support the NHS Pathways audit function.

Verbatim wording from the response

“We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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

Change call-volume forecasting and review rotas to align clinician capacity with demand.

Verbatim wording from the response

“b. A change to the way we forecast volumes of calls, together with a rota review, to try better to align clinician capacity with demand.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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 technology-based solutions to streamline the NHS Pathways audit process.

Verbatim wording from the response

“We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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 dedicated, time-protected staffing for NHS Pathways audits.

Verbatim wording from the response

“We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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 a new strategy to address the paramedic and crew resourcing deficit through a scheduled resourcing-team and operations-management meeting.

Verbatim wording from the response

“Despite these challenges, we are taking measures to try to improve our recruitment of crew. The introduction of the Ambulance Response Programme (ARP) in November 2017 has led discussions surrounding a different skill mix requirement in our crews and this is being monitored at our workforce and business planning meetings, the first of which was in January 2018; this group will continue to meet over the next few months, using latest data to map out what our requirements are against call volume, call categorisation and vacancy rates. This is constantly evolving. We have also planned, for later this month, a meeting between our resourcing team and our Operating Unit Managers to work towards a new strategy to address our resourcing deficit.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 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 the Band 4 technician workforce to meet demand.

Verbatim wording from the response

“a new measure as we had been restricting our recruitment to degree qualified paramedics. We are also increasing our Band 4/Technician workforce to meet demand.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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

Obtain approval for and implement a project plan introducing recruitment and retention changes for Emergency Operations Centre clinicians.

Verbatim wording from the response

“To address this issue, Secamb have created a project plan to address our EOC issues, including the implementation of radical changes to the recruitment and retention of the EOC clinicians. This plan is currently with the Director of Operations for sign-off and will then be presented to the Trust’s Executive for approval, after which it will be implemented. I attach a summary of the plan. Our initiatives also include:”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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

Assess recruitment of IHCD-qualified paramedics as a new recruitment route.

Verbatim wording from the response

“We are exploring the possibility of recruiting IHCD qualified paramedics – those who do not have a degree but qualified following an “on the job” training route. This is”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 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

Recruit newly qualified paramedics through live advertising and a scheduled assessment day.

Verbatim wording from the response

“The Chichester and Worthing area currently has 14 vacancies, of which seven will be filled by qualifying students in March/April 2018, leaving seven truly outstanding vacancies. We have a live advert for newly qualified paramedics and have an assessment day planned for 3 February 2018.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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 reporting and recording systems to monitor NHS Pathways audit performance.

Verbatim wording from the response

“We are aware of the current shortfall in compliance with NHS Pathways audit requirements, this has been identified as a “CQC must do” and appears on the Trust’s corporate risk register. A structured plan has been created and is in progress to rectify this. The plan involves:”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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

Recruit and train Support Call Takers to conduct welfare callbacks and escalate clinically concerning cases.

Verbatim wording from the response

“a. The creation of a new role – “Support Call Taker”. This is a non-clinical role designed to alleviate the pressure on EOC clinicians. The Support Call Takers will work in the EOC carrying out welfare callbacks. This means that where we are not able to dispatch an ambulance resource within the target time, the SCT will call the patient or the caller to ensure that the patient has not got any worse and to offer advice on such matters as keeping warm, staying hydrated and taking prescribed medication. The SCT will have the power to escalate to a clinician any patient about whom there are clinical concerns. We are recruiting and training for this role now.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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 the Surge Management Plan with time parameters and escalation controls for demand exceeding available resources.

Verbatim wording from the response

“c. A change to the way we deal with situations where actual demand for our resources on any shift exceeds forecast demand and therefore exceeds available resources. For a number of years, we have had in place a Demand Management Plan to cope with this situation. This is no longer appropriate, since the introduction of the Ambulance Response Programme (“ARP”). ARP is a national program instigated by NHS England to address the inappropriate categorisation of 999 ambulance calls and dispatch of resources to them. ARP has introduced a new set of nationally prescribed categorisations and response times. I attach a chart summarising the new system. The objective is to match the resource requirements. Secamb introduced ARP on 22 November 2017.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 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 workforce and business-planning data to determine required crew skill mix and staffing levels.

Verbatim wording from the response

“Despite these challenges, we are taking measures to try to improve our recruitment of crew. The introduction of the Ambulance Response Programme (ARP) in November 2017 has led discussions surrounding a different skill mix requirement in our crews and this is being monitored at our workforce and business planning meetings, the first of which was in January 2018; this group will continue to meet over the next few months, using latest data to map out what our requirements are against call volume, call categorisation and vacancy rates. This is constantly evolving. We have also planned, for later this month, a meeting between our resourcing team and our Operating Unit Managers to work towards a new strategy to address our resourcing deficit.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 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.1

  1. 1

    Remodel the ambulance fleet toward 90% Double Crewed Ambulances and 10% Single Response Vehicles.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.

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

  1. 1

    Home working and shared rotational working with GPs cannot yet be implemented because their viability remains under assessment.

    Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Remodel the ambulance fleet toward 90% Double Crewed Ambulances and 10% Single Response Vehicles.

Verbatim wording from the response

“d. Our fleet is being remodelled in order to provide the most appropriate resources to meet demand. We currently have a mix of approximately 70% Double Crewed Ambulances (a “traditional” ambulance that can transport a patient to hospital) and 30% Single Response Vehicles (an ambulance car, crewed by just one paramedic and not designed for transporting patients to hospital). We are moving to 90% Double Crewed Ambulances and 10% Single Response Vehicles. This will take around two years to roll out.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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

Home working and shared rotational working with GPs cannot yet be implemented because their viability remains under assessment.

Verbatim wording from the response

“We are considering further radical changes such as home working, and shared rotational working with GPs; these possibilities are under discussion at the moment and will be subject to viability assessments before a decision can be made as to whether to implement them.”

Source location

2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 3 · response
Published 27 February 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