PATIENT SAFETY: An ambulance pilot that could have contributed to the death of at least one patient had no ‘risk assessment and limited risk management’, NHS England has concluded.

  • NHS England concludes ambulance pilot had “limited risk management”
  • South East Coast Ambulance increased the time some patients waited for a response by 10-20 minutes
  • Investigators unable to identify decision makers about the pilot due to “lack of documentation”

Around 26,000 patient calls were affected by a two month pilot by South East Coast Ambulance Service Foundation Trust, which increased the length of time patients waited for an ambulance response to certain calls by 10-20 minutes.


No conclusions could be reached about the ‘safety and efficacy’ of the pilot

Between December 2014 and February 2015, “red 2” and “green 2” calls to NHS 111 were retriaged by the 999 service, giving handlers either 10 or 20 minutes extra to assess patients.

An investigation by NHS England, released yesterday, said the pilot was set up by an executive committee, which included several board members. The investigators said there was no engagement with patients or the 111 service over the pilot, and no formal approval from all the executives, trust board or lead commissioner.

The report said: “The project was not suitably managed. There was no formal project initiation process nor a clear evidence based project plan. There was no stakeholder engagement, no financial planning, and no formal approval by all the executives or board. There was no timely data collection and evaluation, with no risk assessment and limited risk management.”

However, the investigators were unable to determine who made decisions about the pilot because of a “lack of documentation and the lack of information”.

The authors said it was “disappointing” that no conclusions could be reached about the “safety and efficacy” of the pilot because it “may well have helped urgent care communities across England”.

The investigators looked at 400 documents, visited the operations centre and carried out 16 interviews with “key individuals”.

The Department of Health introduced a pilot in January that allowed two ambulance services to add two minutes on to all response times, apart from the most life threatening, so the call handlers had more time to assess calls to judge if they needed an ambulance response.

The investigators said it was a “concern” that the board was not told about the service’s own pilot considering the time chosen to assess calls was seven minutes longer than the DH pilot.

Emails, seen by HSJ, show trust chief executive Paul Sutton was made aware of commissioners’ concerns about the pilot on 3 February. The pilot was eventually shut down at the commissioners’ request on 24 February.

A whistleblower told HSJ he raised concerns with executives throughout the duration of the pilot but said he was ignored.

He then raised his concerns with Swale Clinical Commissioning Group on 17 February. The CCG responded “appropriately” and this “led to the incident reporting system being reviewed which uncovered further concerns”, the report said.

The report said it took 21 days for the commissioners to review and then advise the ambulance service to stop the pilot.

It added: “It must also be noted that [the trust] could at any point have stopped the pilot and did not need to wait for the commissioners.”

Senior figures were unaware of the project, including the head of compliance, staff at the NHS 111 call centre and the medical director.

Paramedics were brought into the operations centre to call patients back who had initially called the 111 line to check if they needed an ambulance response.

Paramedics had only one day of training to carry out telephone triage and use the IT system. Two paramedics left the project because they found it too stressful.

When paramedics were not available clinical supervisors had to retriage the calls with no extra training.

Clinical supervisor staff submitted a “grievance” to the trust, alleging a failure to “engage, consult or involve” them in the pilot process.

NHS England did a detailed review of seven serious incidents related to the increased response time pilot.

This included a 60-year-old man who died after a 10 minute delay in sending an ambulance to the scene.

The investigators concluded this was “a missed opportunity for the project to have improved a clinical outcome”.

In another incident there was a nine minute delay in responding to an eight-day-old baby. The clinical outcome for the child is not known because it was not recorded in the trust’s records.

The investigators said they were “not convinced of the need for a detailed ‘look back’ exercise as there is an inherent risk in an ambulance service, due to the life critical nature of the calls they receive”, and the time needed to review each patient involved within this project “would be considerable”.

Katherine Murphy, chief executive of the Patients Association, said: “The findings of this report are very damning and paint a worrying picture. It is unacceptable for NHS England to say they cannot identify who gave the instructions to downgrade calls to 111 services in the South East. These decisions placed the public at risk and their actions were completely inexcusable.”

Mr Sutton said patient safety is “fundamental to what we do”. He added: “We recognise that the proper processes were not fully followed in setting up the project and we apologise for this. The decision was made during a time of high patient demand and the pilot was undertaken to ensure that we were able to respond promptly to the most seriously ill patients during this time.

“We fully accept the recommendations in the NHS England report and have already started to act upon them.”