PFD report

MARGARET STEMP · Prevention of Future Deaths report

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Issued 25 Jun 2018•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
10

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. Lack of clinical oversight of ambulance stand-down decisions
    Part of recurring concern: Unreliable ambulance stand-down decisions
  2. Reliance on Police to provide necessary welfare support
    Part of recurring concern: Unreliable allocation and referral of welfare support between police and ambulance services
  3. Insufficient resources for handling high call volumes
    Part of recurring concern: Insufficient ambulance service capacity for emergency calls
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.10

  1. Action

    Require ambulance stand-down decisions to undergo two-step verification by a Dispatch Team Leader or Clinical Navigator.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2018.
  2. Action

    Purchase approximately 100 new ambulances over three years to increase ambulance capacity.

    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 10 July 2018.
  3. Action

    Carry out a Demand and Capacity Review with commissioners to determine required resources and how they will be provided.

    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 10 July 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

Lack of clinical oversight of ambulance stand-down decisions

Wider context from the report

“(4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance stand-down decisions.

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

Reliance on Police to provide necessary welfare support

Wider context from the report

“(2) That the Police had to be used to provide the necessary welfare support to these ladies ”

Is this part of a recurring concern?

Yes — Unreliable allocation and referral of welfare support between police and ambulance services.

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

Insufficient resources for handling high call volumes

Wider context from the report

“(1) That there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours and what would have been considerably longer had the Police not attended. ”

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

Failure of call takers to recognise worsening condition

Wider context from the report

“(3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration.

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

Require ambulance stand-down decisions to undergo two-step verification by a Dispatch Team Leader or Clinical Navigator.

Verbatim wording from the response

“As a result of this incident, the procedure for standing down an ambulance has now been changed. A Support Call Taker can no longer stand down an ambulance. A two-step verification process has been introduced whereby they must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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

Purchase approximately 100 new ambulances over three years to increase ambulance capacity.

Verbatim wording from the response

“b. We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 10 July 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

Carry out a Demand and Capacity Review with commissioners to determine required resources and how they will be provided.

Verbatim wording from the response

“c. We are, together with our commissioners, carrying out a “Demand and Capacity Review”, which will enable both parties to determine:”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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 enhanced deterioration-recognition training to new Support Call Takers during induction.

Verbatim wording from the response

“As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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 enhanced training to existing Support Call Takers on recognising deterioration and responding appropriately.

Verbatim wording from the response

“As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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 an audit system for Support Call Takers’ work, including audit criteria and scoring.

Verbatim wording from the response

“As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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 a Patient Welfare Procedure requiring Support Call Takers to work with Clinical Navigators to manage waiting calls clinically.

Verbatim wording from the response

“As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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

Purchase second-hand ambulances to address anticipated winter demand pressures.

Verbatim wording from the response

“b. We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 10 July 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 procedures safeguarding fallen patients’ welfare while they await an ambulance.

Verbatim wording from the response

“I am grateful to the Police for their assistance on this occasion, however I fully accept that the welfare of patients is SECAmb’s responsibility, not that of the Police. Since this incident, we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in a timely manner. I attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while they are awaiting an ambulance.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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

Review the forecasting model to improve prediction of hourly resource requirements and system pressures.

Verbatim wording from the response

“d. We have planned a review of our forecasting model, with the objective of better anticipating what resources will be needed for any hour of any day, making provision for system pressures.”

Source location

2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 10 July 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