Please note that as an NHS trust we follow the NHS England Serious Incident Framework (2015). This describes Serious Incidents (SIs) in the context of delayed response as ‘acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm’.
EMAS has established a twice-weekly Incident Review Group (eg senior clinicians) which meets to determine if a delayed response incident meets the criteria for reporting it as an SI. All cases where there has been an adverse patient outcome (including death) and where there has been a delay in ambulance response, are reviewed. This includes a review of:
- the 999 call to check that the call was categorised correctly
- the actions taken by the ambulance dispatchers in the control room to ensure that protocols for dispatch were followed, and
- the ambulance resources available to attend at the time of the incident.
Where it is established that the adverse outcome experienced by the patient was, on the balance of probabilities, more likely than not to have been as result of the delay in response, the incident is recorded as an SI and reported to NHS England. This includes incidents where the call was correctly coded and dispatch protocols have been followed, but where there were simply no available ambulances to send sooner.
All cases are thoroughly investigated and the patient’s family are also invited to contribute to the terms of reference for any investigations. The investigation includes a review of both internal factors (eg ambulances available) and external factors (eg NHS and 999 demand/hospital handover delays) which impacted our ability to respond, and outcomes are shared with the families, our commissioners (eg NHS England and Integrated Care Systems) and regulators (eg Care Quality Commission).
Not all incidents reviewed meet the SI criteria due to the fact that, on the balance of probabilities, it is determined that the delay did not impact the outcome. Examples may include:
- where the death is expected and the patient is on an end of life pathway with a Do Not Attempt Resuscitation instruction in place
- where on arrival there are unequivocal signs of death that indicate that the patient was likely deceased prior to the call to 999, eg established rigor mortis,
- where it is established that the outcome would likely have been the same even had a more timely response be received. An example of this would be catastrophic injuries as a result of major trauma such as a serious Road Traffic Collision.
At EMAS we remain concerned by the increasing number of SIs related to delayed responses. We continue to take all actions possible to reduce delayed responses to our patients, including working closely with the healthcare systems, our control room staff and ambulance crews seek alternative treatment pathways for their patients to prevent them from needing to travel to hospital, and maximising the number of resources available to respond to patients (as recorded via our Trust Board meeting papers available via our website). In addition, we continue to regularly escalate our concerns to NHS England.
This concern is echoed across the UK ambulance sector, therefore please also see the latest statement from the Association of Ambulance Chief Executives:
Association of Ambulance Chief Executives Managing Director Martin Flaherty OBE QAM said:
"Firstly we must recognise the never-ending hard work and dedication of the NHS ambulance sector's staff who are doing their utmost to continue responding to patients when they need us most.
"However, the current pressures on the ambulance service are unprecedented and have been building for some time. The ultimate safety net for the NHS is the fact that patients who are severely ill or injured can access an emergency ambulance in a timeframe appropriate to their clinical condition, but we know that safety net is now compromised because of pressures throughout the health and social care system.
"The single biggest issue impacting the ambulance sector's ability to respond appropriately is unprecedented delays handing over patients at emergency departments. AACE has been raising these concerns for months and published the first ever report into the harm being caused in November 2021. Since then the situation has continued to deteriorate and is having an intolerable impact on our patients and our staff.
"The answer is not simple but it is straightforward. Hospitals and their supporting system partners must find a way of creating and staffing additional capacity to take ambulance patients into the hospital as soon as the ambulance arrives."
"AACE has made it clear that for this to happen requires clear leadership and we have welcomed the desire for early collaboration with ambulance leaders by the new Secretary of State for Health and the renewed push by NHSE to make this happen and we hope the recent letter from NHSE to all acute trusts will have a positive effect in helping eliminate these delays. When that happens, the ambulance service will be able to revert back to delivering the consistent performance that the public has rightly come to expect.”