PFD report

Christina Avis RUSE · Prevention of Future Deaths report

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Issued 26 Aug 2022•Norfolk

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised1

  1. Insufficient emergency ambulance availability for timely patient response
    Part of recurring concern: Delays in ambulance attendancePart 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.4

  1. Action

    Review the current delay action plan.

    Stated by EASTStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  2. Action

    Participate in daily system calls with hospitals and other stakeholders to address lengthy handover delays and interim measures.

    Stated by EASTStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
  3. Action

    Operate the Category 1 drop-and-go process to release crews for Category 1 emergencies.

    Stated by EASTStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.

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 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. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Insufficient ambulance service capacity for emergency calls.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review 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
Page 1 · response
Published 3 October 2022

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Participate 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
Page 1 · response
Published 3 October 2022

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate the 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
Page 1 · response
Published 3 October 2022

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
Page 1 · response
Published 3 October 2022

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.4

  1. 1

    Share the AACE briefing on hospital handover delays and delayed ambulance responses with the coroner’s office.

    Stated by EASTStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  2. 2

    Work with regional system partners to protect patients during the period of hospital handover delays.

    Stated by EASTStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
  3. 3

    Work with HSIB to continue escalating concerns about ambulance service pressures and delayed handovers.

    Stated by EASTStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
  4. 4

    Continue regular executive-level escalations to address hospital handover delays.

    Stated by EASTStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.

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

Share the AACE briefing on hospital handover delays and delayed ambulance responses with the coroner’s office.

Verbatim wording from the response

“Furthermore, the Association of Ambulance Chief Executives (AACE) released a briefing for HM Coroners in relation to hospital handover delays and delayed ambulance responses to 999 calls and this was shared with your office on 30 August 2022. I have also attached a copy for your information.”

Source location

Response from East of England Ambulance Service
Page 2 · response
Published 3 October 2022

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with regional system partners to protect patients during the period of hospital handover delays.

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
Page 1 · response
Published 3 October 2022

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with HSIB to continue escalating concerns about ambulance service pressures and delayed handovers.

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
Page 1 · response
Published 3 October 2022

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 escalations to address 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. As 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
Page 1 · response
Published 3 October 2022

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