• Serious incident reports reveal one call put on hold for 10 minutes
  • Control room staff suffered stress and anxiety and considered suicide
  • Trust says it has recruited more control room staff

A shortage of ambulance control room staff, which left 999 calls unanswered for up to 10 minutes may have led to the deaths of two patients, HSJ can reveal.

South East Coast Ambulance Service Foundation Trust investigated 10 serious incidents related to call answering delays in 2017-18. In eight of these cases, the patients died, either at the scene or later. After investigation, two of these deaths were categorised as directly related to the trust’s involvement.

In one of the 10 cases, the parents of a three week old baby called 999 but the call could not be answered in the nearest emergency operations centre. The parents started to drive the baby to hospital and flagged down an ambulance on the way: the child died shortly after reaching hospital.

In another case, a call for a patient who was not breathing took seven minutes to answer: when a paramedic reached the patient they could not be resuscitated.

One serious incident report says a 999 call was put on hold for 10 minutes before being answered.

A separate review of patient harm during the period of heavy snow in late February/early March shows that the pressures led to harm for at least two, and possibly three, patients. The review, obtained by HSJ under the Freedom of Information Act, shows that EOC staffing was below plan in each case and said there was a common factor in “the inconsistent capability of emergency operations centres to carry out patient callback” which impacted on the ability to recognise if a patient was deteriorating.

Papers obtained by HSJ refer to turnover of emergency medical advisors who answer 999 calls as leading to “significant stability issues within the EOC” and putting additional strain on those staff that remained; the trust was not able to provide the 4500 EMA hours per week it needed and sometimes fell below 3500.

The trust saw very high turnover of EMAs in 2017-18 with 145 leaving and an internal report shows it had under 120 in post in February, excluding new starters, against a baseline of 171 whole time equivalents. That month, the board was told the “trust has not invested sufficiently in recruitment and retention within the EOC”. The trust has also seen call volumes significantly higher than the previous year with up to 18 per cent of calls being people calling a second time.

Sickness rates among EMAs peaked at almost 17 per cent in September last year.

A SECAmb spokesman said: “During the last year we have made a number of improvements to the way we handle calls in EOC. This includes introducing a new role of clinical safety navigator, performed by a senior clinician in our EOCs, to minimise the potential risks for patients waiting for a response.”

They added a new computer dispatch system and the opening of a new call centre in Crawley was also helping to improve the situation.

The trust has launched a “significant recruitment drive” and currently had 184 full time equivalent EMA staff with 33 of these in the process of completing their training in coming weeks. This staffing is in line with the trust’s budgeted plans.

The spokesman said: “We are also continuing to focus on improving our call answer performance and recruitment and retention plays a key part in this. We are pleased that our mean monthly call answer times have fallen dramatically since the winter.

“However, we recognise that there remains more work to [be] done. This work is mainly driven through our EOC task and finish group with other areas of key focus including training, sickness, shift scheduling and processes.”