Ambulance delays a ‘factor’ in 104 deaths in one region during final quarter of 2022

According to the South West Ambulance Service Foundation Trust, 104 patient deaths reviewed under National Quality Board guidelines in quarter three of 2022-23 related to delays “which are thought to be a result of pressures within the wider health system”.

The trust has stressed the deaths were not necessarily directly caused by delays, but that delays were a “common factor” in the 104 cases.

Since July 2019, all ambulance trusts have been required to implement Learning from Deaths reviews following a report by the Care Quality Commission three years earlier, which found that opportunities were being missed to learn from patient deaths.

A total of 876 incidents were identified as being within the scope of a review at the end of last year by SWASFT, of which 210 were reviewed.

Deaths included in the review occured while the patient is under the care of the ambulance service, from the initial 999 call being made to their care being transferred to another part of the system or to the point where a decision is made not to convey them to hospital.

Of the cases reviewed, seven received the lowest score of 1 – indicating “very poor care” – all due to “delays believed to result from system pressures”, while 58 scored a 2 – indicating “poor care” – all but one of which related to delays.

Four cases have so far been declared as meeting the threshold for serious incidents where a delayed response was “deemed to be as a result of pressures within the wider healthcare system rather than ambulance demand alone”.

According to SWASFT board papers, the figures are “reflective of the pressure seen on the service during quarter three”.

The trust, which serves over 5.5 million people, declared a critical incident in December due to “extreme demand” and reported activity of up to 3,400 call-outs – or “incidents” –  per day.

For the week commencing 26 December 2022, more than 19,000 hours were lost to delays in handover times, resulting in average handover times exceeding three hours per patient which was “by far the worst week recorded in trust history”. 

National data revealed a total of 55,000 hours were lost to delays during the same week across all English ambulance trusts, and an investigation by The Guardian published last month found more than 500 patient deaths were because of ambulance delays.

SWASFT board papers also said that the “unprecedented volume” of incidents in December alone may have impacted the trust’s ability to “keep abreast of reviews” into patient deaths.

A spokesman for SWASFT said: “From October to December 2022, a number cases were identified through the learning from deaths process, where patients sadly died and also experienced a delay in our response. Four of these cases were included under the trust’s thematic Patient Safety Incident Investigation.

“Whilst a delayed response is a factor, it may not be the overarching reason for the outcome more generally. Like all trusts, we continue to work hard to improve patient safety wherever possible and take away any identified key learnings. We would like to offer our sincere condolences to the family and loved ones of the patients who have died.”