A patients group has dubbed an official report into a controversial ambulance call system which put patient safety at risk “a whitewash and a major scandal”.
The South East Coast Ambulance Trust (SECAmb) have been issued with 11 recommendations after an investigation into the trial, which delayed up to 26,000 calls referred from 111 to 999.
An NHS England report published this lunchtime says health regulator Monitor will now undertake three comprehensive reviews into the trust’s decision making, governance and any potential patient harm which arose as a result of the trial.
And NHS England has drawn up a list of recommendations for the trust to follow after conducting its own investigation.
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.
“This is a whitewash and a major scandal. Yet again the Clinical Commissioning Group failed to monitor the quality and safety of the contract. The Patients Association express our deep concern with ongoing patient safety issues of this nature.
“There has been no accountability, no transparency in the investigation and absolutely no assurance for the safety of the public. The Patients Association call today for an independent investigation into this serious failure of care.
“The facts surrounding the decision making must be established. The public deserve better.”
A spokesman for NHS ENgland said: “The report makes clear that this project was initiated entirely within South East Coast Ambulance Service and resulted in changes to the handling of calls within the 999 service, not the 111 service. The regulator, Monitor, will oversee the next steps with the trust.”
The report says the trust started re-triaging 111 calls referred onto its 999 service after an increase in such calls last winter affected its ability to respond within 8 minutes, coupled with delays at hospital resulting in paramedics being unable to hand patients over to A&E.
For three months from December 20, it re-triaged 26,000 calls referred to it from 111, resulting in another 10-minute wait for calls which had requested an ambulance, and 20 minutes for less urgent calls.
But even though the 111 operators were also employed by SECAMB, they were not made aware of the new system, and the changes were not flagged up at the trust’s committees, including its risk management committee.
Concerns were flagged up to the trust’s head of compliance by a clinical supervisor just three days after the project started, but were not investigated after they were told the trial would finish within days. It carried on for another three months.
Swale Clinical Commissioning Group in Kent then flagged up concerns after a serious incident on Feb 3, then on Feb 17, a whistleblower sent an anonymous email. Further clinical incidents came to light on Feb 23, and the project was suspended the following day.
The recommendations are:
- simplify governance and ensure it’s not circumvented
- patients and carers to be involved at all levels
- unequivocal transparency
- leadership must promote quality and clinical governance
- everyone understands responsibilities and accountabilities in improvement projects
- commissioners not providers should decide what they want provided
- The CCG to identify in their contract how trust changes standards
- Investigations to include families
- Formal reporting structures for commissioners and accurately minuted meetings
- Improve SECAmb internal organisation
- Organised engagement with patients
