Trust withheld key details of deaths, review finds

The review, commissioned by NHS England, examined allegations that North East Ambulance Service had not disclosed key information.

The inquiry looked at four cases that occurred over a 12-month period up to December 2019 and found that NEAS had delayed telling coroners about care failings, omitting key details from reports before eventually disclosing them later on.

It also criticised NEAS for its “poor” handling of families’ concerns. HSJ has previously reported concerns that there could be up to 90 cases where procedures for reporting to the coroner were not followed.

The review, led by Dame Marianne Griffiths, former chief executive of University Hospitals Sussex, also found that “leadership dysfunction was allowed to continue for far too long” at NEAS, in which “a defensiveness grew and affected team operations, transparency, candour and judgement” and also impacted the health and wellbeing of staff. It said some staff “still report being frightened to raise concerns or to challenge those in authority”.

While the inquiry noted “good progress” being made on addressing these issues, it said “there remains a lack of independent review” in its coronial processes. The report warned that if there is no impartial or independent review of these cases “the same problem may recur”.

NEAS has apologised to the families for “mistakes made in the past,” and said “flaws” in its processes for disclosing information about deaths “have now either been addressed or are being resolved at pace”.

NEAS also said it has accepted the recommendations in the report, which includes involving an independent “senior doctor” in the review of deaths and their referral to coroners. The ambulance service said it is working with Northumbria Healthcare Foundation Trust to implement a “medical examiner” approach to reviewing deaths.

One family has described the report as a “whitewash”. Whistleblowers have previously raised concerns about the “limited scope” of the inquiry, having raised concerns about disclosure in more than 90 cases. However the report has said it has looked at previous external reviews which have considered a greater number of cases.

Trust ‘did not inform coroner about investigation’

The review found that NEAS had not informed the coroner about an investigation into the death of 17-year-old Quinn Beadle in December 2018 [referred to in the report as patient A] “as it was required to do so”.

An initial review found the first paramedic to respond did not attempt “full advanced life support” before declaring Quinn’s death, but that this should have been attempted. The paramedic, Gavin Wood, has since been struck off.

This initial report was “directed to be altered by a ‘Strategy Group’ who disagreed with the outcome” before it was shared with the coroner and the family, the inquiry said.

It showed that the group was attended by senior staff at the trust including the then medical director.

The coroner was not notified about the concerns and the investigation by the trust and only found out through the Police Professional Standards Body, the review found, leading the inquest to be adjourned. The inquiry also said NEAS should have reported this as a serious incident, but “this was not done”.

‘Whitewash’

Tracey Beadle, Quinn’s mother, told HSJ that the report was a “complete whitewash” due to issues including its limited scope and key details being omitted from previous investigations, and that the review failed to examine why the Care Quality Commission did not take action when concerns were raised with them. She also questioned the suitability of Dame Marianne to lead the review, given cultural problems previously highlighted at her former trusts.

“This is the NHS investigating the NHS,” she said. “Therefore no impartiality exists.”

She added NEAS “have [been] afforded protection from [CQC and NHSE], putting their reputations before the safety and wellbeing of patients”.

‘We’re sorry we let the families down’

In response to the independent review’s findings, Helen Ray, chief executive of NEAS, said each family has received an unreserved apology “for mistakes made in the past”, and that all recommendations in the inquiry are “being actioned at pace”.

She told HSJ: “We’re very sorry that at a point in time when the families needed us, we let them down. We can’t undo that, but we have taken a lot of actions to make sure the lessons from these cases have been learned by the organisation and changes have been made.”

The report also said NEAS needs more financial support, claiming it has “not been adequately funded for the service required”.

Mrs Ray, who joined NEAS in 2019, replacing Yvonne Ormston, who ran the trust for five years, told HSJ that NEAS has now been given a “good level of funding” to recruit more paramedics and call handlers, and the trust has also invested in its Freedom to Speak Up Guardians. She also said NEAS is working with Northumbria Healthcare FT on implementing a medical examiner model to review deaths. But she said “it’s very clear that the organisation needs a medium and long-term funding solution.”