PATIENT SAFETY: An ambulance trust is to review how it uses GPs in its emergency operations centres after a patient died when a GP downgraded the response.

A serious incident report for South East Coast Ambulance Service Foundation Trust has revealed a 33-year-old man, who was drunk and had difficulty breathing and chest pains, waited more than an hour for an ambulance after his case was initially assessed as “red two” – meaning an ambulance should be with him within eight minutes.

A GP effectively overrode the decision – made after using NHS Pathways triage – and downgraded the call to a “category C” 60 minutes response. By the time a crew arrived, the man was in cardiac arrest and later died in hospital.

The report says “a lack of governance for the GPs has led to a number of significant issues occurring”, which included the GP intervening without sufficient information and failing to probe sufficiently during a call to a relative. This led to missed “red flags” and the incident, in May last year, not being prioritised appropriately.

A number of “near miss” issues were also uncovered including GPs possibly not knowing enough about NHS Pathways to understand concerns raised during triage, no scheduling system for GPs within the emergency operations centre, and insufficient procedures to define how and when a GP could intervene on a call.

The trust is now reviewing how GPs work within the control room, improving their induction and mentoring, and looking at other governance issues.