Commissioners warned that a controversial South East Coast Ambulance Foundation Trust pilot that added 10 minutes to some emergency response times may have contributed to the death of at least one patient, leaked emails seen by HSJ reveal.

  • 60-year-old man who died “may have had a different outcome” if the ambulance service had not increased response times
  • Commissioners had “very real concerns” that at least one serious incident was caused by making 111 callers wait longer than 999 callers

In one email, the head of quality and safety for clinical commissioning groups in north Kent warned colleagues in February that a 60-year-old man who died awaiting an ambulance “may have had a different outcome” if the trust had not increased its response times for some “red 2 calls”. These calls are serious but not the most life threatening.


The trust ran a pilot that increased the length of time patients waited for some calls by up to 10 minutes

Between December 2014 and February 2015 the service ran a pilot that increased the length of time patients waited for an emergency response to certain calls by up to 10 minutes.

Monitor is taking action against the trust as a result of this pilot.

In the email seen by HSJ, North Kent CCGs head of quality and safety Nikki Teesdale highlighted a serious incident requiring investigation that had been reported by the ambulance trust the previous day.

She wrote: “At the program board it was mentioned… that they are retriaging all calls that come through from 111 to 999 – classified as a ‘red 3’. This causes a 10 minute delay in response… 999 service are stating that this is a positive step and that ‘hear and treat’ figures have increased significantly. However, this patient in this [serious incident] may have had a different outcome if the call had been put straight through to dispatch and a red 2 response sent which could have arrived in eight minutes prior to him going to agonal breathing pattern”.

She added: “I would suggest that we need to discuss this as a matter of urgency with the possibility of the trust reverting back to their original automatic dispatch until we can be assured that this is safe”.

Swale CCG then emailed the 111 service to say it had “very real concerns that there has already been a serious incident arising from a delayed 999 ambulance dispatch since this new process and have not been assured that the risk of delays for other patients has been mitigated”.

According to an email describing the serious incident, a 111 centre had received a call from the wife of 60-year-old man in Horsham, West Sussex, who reported he was short of breath, had vomited and had pain in his right chest.

He came on the telephone to speak to the handler but “then appeared to go into arrest and his wife started CPR”.

The 111 handler passed the call to the ambulance service’s 999 line and it was treated as a red 3 call, which requires a 10 minute response. This was upgraded to a red 2 call 10 minutes later.

An ambulance was assigned to the call but was delayed for five minutes because the crew was locking drugs away.

The man’s wife rang again who was “extremely upset” and said she had been doing CPR for previous 20 minutes.

When the ambulance crew arrived 20 minutes later they continued CPR but the man could not be revived and was pronounced dead 35 minutes later.

In another email, John O’Sullivan, senior manager for clinical governance and quality at Kent, Medway Surrey and Sussex NHS 111, said there had been three serious incidents in 10 days “that all have an element of concern with respect to the practice of ‘retriaging’ red 2 ambulances”.

A spokeswoman for South East Coast Ambulance said: “We have worked closely with our commissioners since the pilot ended in February to review the process and the impact on patients and a number of cases have been looked at closely together with the commissioners.”