Wyllow-Raine Swinburn
PFD Report
All Responded
Ref: 2025-0064
All 2 responses received
· Deadline: 1 Apr 2025
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Response Status
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56-Day Deadline
1 Apr 2025
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The two concerns relate to, firstly, the length of time for the 999 call to be connected to a ECT (Emergency Call Taker and, secondly, the length of time for an ambulance/paramedic to attend. I fully appreciate there have been very significant demands on ambulance services including on SCAS in the past few years. I also understand, from the written and oral evidence of , that multiple actions have been undertaken to improve ECT staffing and inconsistency. My primary concern is in relation to this first issue. I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times.
It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.
Given the risk associated with delayed response times, particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance.
It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.
Given the risk associated with delayed response times, particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance.
Responses
South Central Ambulance Service has implemented a 'Fit for the Future' programme, significantly increasing clinical staff, reviewing crew skill levels, and enhancing support for new paramedics. A new joint process for ambulance handover at hospitals has been successfully implemented, improving Category 2 response times, and 53 new vehicles have been delivered as part of a fleet update.
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View full response
Dear Mr Salter,
I am writing to you in response to the concerns that you highlighted following the inquest hearing into the very sad death of Wyllow-Raine Lawson Swinburn that concluded on 2nd December 2024. Thank you for allowing us the time to review and respond to your concerns.
To confirm, your Regulation 28 report detailed your concerns regarding the time that it took for the 999 call made on 30th September 2022 to be answered and the time that it took for an ambulance to arrive at Wyllow-Raine’s home address. You confirmed that your primary concern related to the time that it took for the 999 call to be answered. However, I will cover both concerns within this letter to offer you reassurance that the Trust is doing all that it can to provide a safe and responsive service for the communities that we serve.
Thank you for recognising the significant improvements that the Trust had already made by the time the case came to be heard within your Regulation 28 report. The safety of our patients is of paramount importance to the Trust, and we will always actively seek to make improvements where we can.
In relation to call answer time, you are already familiar with the critical call process available where a BT operative becomes aware of, or is informed of, a time critical situation from the evidence provided to you for the inquest by both SCAS and BT. I have therefore not covered this within my letter but can confirm that this process remains in place.
Since December 2023, the Trust has introduced a Fit for the Future programme (FFF). Under this programme the Trust has initiated an improved way of working in various areas of our workforce. The improvements are designed to ensure that we provide our patients with the care that they need safely and effectively in a timely way.
Improvements made within our Clinical Coordination Centre (CCC)
Within the CCC we have undertaken the following work in addition to the work that you have already been informed of via evidence for the hearing:
• We have commenced a remodelling exercise to identify the number of Emergency Call Takers (ECTs) required to deliver a reliable service for the operational demand that we are working to. The increase in call answering ability has resulted in a significant decrease in our average call answer time. As explained to you at the inquest hearing, comparing September 2022 to September 2024, the average call answer time fell from 50 seconds to 10 seconds. In January 2025, this had reduced further to an average call answer time of 8 seconds.
2
• The Association of Ambulance Chief Executives (AACE) is supporting us whilst we are undertaking our improvement plan. The plan is designed to improve call answer times, redesign our rotas, increase the spread of shifts to minimise shift changeover shortages, increase clinical support in the CCC to support ECTs and prioritise early clinical intervention in more complex cases.
• We have commissioned an external organisation, ORH, to review our CCC staffing capacity modelling to ensure we have the correct skill set and operational model which is fit for the future.
• We are continuing to work in partnership with the Isle of Wight NHS Trust to increase ECT numbers and availability.
• We are refreshing our dispatch models to ensure multiple vehicles are not dispatched to an incident to maintain resource availability. This refresh will include a review of the need for continued deployment of a rapid response vehicle when an ambulance arrives.
• We are improving the training and mentorship model for the CCC and have recruited staff internationally to increase clinical support in the room.
Improvements made to road operations:
• To provide additional senior leadership for our operational workforce, we have recruited a Chief Paramedic who sits on the Trust Board.
• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place
• We appointed a People Promise Manager and started exemplar programmes to improve retention of frontline staff. Retention ensures that staff turnover is reduced, and we maintain a skilled workforce with knowledge and experience.
• We increased our paramedic apprenticeship numbers to increase the number of clinical staff that can respond to patients.
• We have reviewed the skill level of crews that are on our ambulances to ensure we have the appropriate skill mix on every resource depending on the incident they are being tasked to. We now have two types of resources, clinical and non-clinical, which are dispatched to patient’s dependent on their needs.
• We have increased the level of support and supervision we provide to newly qualified paramedics.
• Specialist Practitioners are used to provide additional clinical support and increase the use of other care pathways as an alternative to hospital conveyance where this would better suit the patient’s needs.
• The new joint process with our healthcare partners in relation to the amount of time an ambulance crew will wait at a hospital to handover their patient that was discussed at the inquest hearing has been successfully implemented with all hospitals within the SCAS geographical area. This has resulted in our Category 2 response times improving by 6 minutes to an average of 24 minutes in January and February 2025.
Improvements made to our fleet of vehicles:
• We are in the process of updating our fleet of vehicles to increase the reliability of our fleet and reduce occasions where vehicles are out of service or break down during operational use. A total of 124 new vehicles have been ordered, with 53 delivered by the end of 2024.
3 I hope that this letter has adequately addressed the concerns that you have raised. Please do let me know if you would like to be kept updated on the progress of our improvement programme.
Should you wish to discuss these matters further, please contact , Head of Legal Services at SCAS who will be able to arrange a time for us to meet.
I am writing to you in response to the concerns that you highlighted following the inquest hearing into the very sad death of Wyllow-Raine Lawson Swinburn that concluded on 2nd December 2024. Thank you for allowing us the time to review and respond to your concerns.
To confirm, your Regulation 28 report detailed your concerns regarding the time that it took for the 999 call made on 30th September 2022 to be answered and the time that it took for an ambulance to arrive at Wyllow-Raine’s home address. You confirmed that your primary concern related to the time that it took for the 999 call to be answered. However, I will cover both concerns within this letter to offer you reassurance that the Trust is doing all that it can to provide a safe and responsive service for the communities that we serve.
Thank you for recognising the significant improvements that the Trust had already made by the time the case came to be heard within your Regulation 28 report. The safety of our patients is of paramount importance to the Trust, and we will always actively seek to make improvements where we can.
In relation to call answer time, you are already familiar with the critical call process available where a BT operative becomes aware of, or is informed of, a time critical situation from the evidence provided to you for the inquest by both SCAS and BT. I have therefore not covered this within my letter but can confirm that this process remains in place.
Since December 2023, the Trust has introduced a Fit for the Future programme (FFF). Under this programme the Trust has initiated an improved way of working in various areas of our workforce. The improvements are designed to ensure that we provide our patients with the care that they need safely and effectively in a timely way.
Improvements made within our Clinical Coordination Centre (CCC)
Within the CCC we have undertaken the following work in addition to the work that you have already been informed of via evidence for the hearing:
• We have commenced a remodelling exercise to identify the number of Emergency Call Takers (ECTs) required to deliver a reliable service for the operational demand that we are working to. The increase in call answering ability has resulted in a significant decrease in our average call answer time. As explained to you at the inquest hearing, comparing September 2022 to September 2024, the average call answer time fell from 50 seconds to 10 seconds. In January 2025, this had reduced further to an average call answer time of 8 seconds.
2
• The Association of Ambulance Chief Executives (AACE) is supporting us whilst we are undertaking our improvement plan. The plan is designed to improve call answer times, redesign our rotas, increase the spread of shifts to minimise shift changeover shortages, increase clinical support in the CCC to support ECTs and prioritise early clinical intervention in more complex cases.
• We have commissioned an external organisation, ORH, to review our CCC staffing capacity modelling to ensure we have the correct skill set and operational model which is fit for the future.
• We are continuing to work in partnership with the Isle of Wight NHS Trust to increase ECT numbers and availability.
• We are refreshing our dispatch models to ensure multiple vehicles are not dispatched to an incident to maintain resource availability. This refresh will include a review of the need for continued deployment of a rapid response vehicle when an ambulance arrives.
• We are improving the training and mentorship model for the CCC and have recruited staff internationally to increase clinical support in the room.
Improvements made to road operations:
• To provide additional senior leadership for our operational workforce, we have recruited a Chief Paramedic who sits on the Trust Board.
• As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place
• We appointed a People Promise Manager and started exemplar programmes to improve retention of frontline staff. Retention ensures that staff turnover is reduced, and we maintain a skilled workforce with knowledge and experience.
• We increased our paramedic apprenticeship numbers to increase the number of clinical staff that can respond to patients.
• We have reviewed the skill level of crews that are on our ambulances to ensure we have the appropriate skill mix on every resource depending on the incident they are being tasked to. We now have two types of resources, clinical and non-clinical, which are dispatched to patient’s dependent on their needs.
• We have increased the level of support and supervision we provide to newly qualified paramedics.
• Specialist Practitioners are used to provide additional clinical support and increase the use of other care pathways as an alternative to hospital conveyance where this would better suit the patient’s needs.
• The new joint process with our healthcare partners in relation to the amount of time an ambulance crew will wait at a hospital to handover their patient that was discussed at the inquest hearing has been successfully implemented with all hospitals within the SCAS geographical area. This has resulted in our Category 2 response times improving by 6 minutes to an average of 24 minutes in January and February 2025.
Improvements made to our fleet of vehicles:
• We are in the process of updating our fleet of vehicles to increase the reliability of our fleet and reduce occasions where vehicles are out of service or break down during operational use. A total of 124 new vehicles have been ordered, with 53 delivered by the end of 2024.
3 I hope that this letter has adequately addressed the concerns that you have raised. Please do let me know if you would like to be kept updated on the progress of our improvement programme.
Should you wish to discuss these matters further, please contact , Head of Legal Services at SCAS who will be able to arrange a time for us to meet.
BT clarified that their operators remain online during 999 calls, listening and providing comfort, and also hear queue announcements from Ambulance Trusts. They detailed their existing Critical Call Process for identifying and prioritising calls with imminent risk to life, noting that distress alone is not an agreed trigger.
AI summary
View full response
Dear Mr Salter,
Inquest into the death of Wyllow-Raine Swinburn
Thank you for raising the questions with me and allowing an opportunity to respond. I apologise for the delay in answer as I did not receive the written letter. I provide the answer to your questions below:
1. I understand a BT Operator will listen to the caller/background noise to identify if the call is critical. I am not clear if this happened in this case?
The BT Operator remained online with the caller listening and providing comfort messages until the Ambulance answered the call. Paragraph 14 of my statement refers.
2. I am not clear if, routinely, an operator continues to listen for the duration (before connection to the ambulance service) and while the caller is on hold or simply has the ability to listen in periodically while also taking other calls.
The BT operator will listen until the Ambulance Service answer unless the temporary procedure contingency is used. Paragraphs 12 and 13 of my statement refer.
3. A further concern was raised by family that the automated message that repeats itself continuously could potentially interfere or drown out what is being said or happening at the caller's end if indeed the automated message is one that is also heard by the BT operator.
The BT Operator will also hear the queue announcement played by the Ambulance Trust. The Pecs Code of Practice provides guidance for Emergency Services with regards the queue announcement. If BT has any
British Telecommunications PLC Registered Office: One Braham Street, London E1 8EE Registered in England No 1800000
Relationship Manager Emergency Authority and Government
concern regarding the volume or timing of a particular queue announcement impacting on call handling, this is fed into the particular Emergency Service. Paragraph 15 of my statement refers.
4. Finally, it is understood the Critical Call Process was not used on the call in question. A concern that I have is whether BT has an effective process in place to identify a critical call and prioritise it accordingly
BT has a Critical Call Process to identify a critical call where the BT Operator hears speech or sound that indicate an imminent or immediate risk to life. BT has agreed with Ambulance Trusts nationally which category of calls they consider critical and would trigger the Critical Call Process if the BT Operator were to hear speech or sound to suggest those scenarios. Paragraphs 3, 4 and 10 of my statement refer. Distress alone is not an agreed trigger for the Critical Control Process. Critical calls are prioritised by connection to the Trust secondary line which is at the head of their queue. Paragraph 7 of my statement refers. If the Trust does not quickly answer, the BT Operator will connect to another Trust secondary line. BT also hold a Critical Contact number for each Trust as documented in section
4.1 of the PECS included in Exhibit KS1.
I hope that this information provides the required clarification on the points raised.
Inquest into the death of Wyllow-Raine Swinburn
Thank you for raising the questions with me and allowing an opportunity to respond. I apologise for the delay in answer as I did not receive the written letter. I provide the answer to your questions below:
1. I understand a BT Operator will listen to the caller/background noise to identify if the call is critical. I am not clear if this happened in this case?
The BT Operator remained online with the caller listening and providing comfort messages until the Ambulance answered the call. Paragraph 14 of my statement refers.
2. I am not clear if, routinely, an operator continues to listen for the duration (before connection to the ambulance service) and while the caller is on hold or simply has the ability to listen in periodically while also taking other calls.
The BT operator will listen until the Ambulance Service answer unless the temporary procedure contingency is used. Paragraphs 12 and 13 of my statement refer.
3. A further concern was raised by family that the automated message that repeats itself continuously could potentially interfere or drown out what is being said or happening at the caller's end if indeed the automated message is one that is also heard by the BT operator.
The BT Operator will also hear the queue announcement played by the Ambulance Trust. The Pecs Code of Practice provides guidance for Emergency Services with regards the queue announcement. If BT has any
British Telecommunications PLC Registered Office: One Braham Street, London E1 8EE Registered in England No 1800000
Relationship Manager Emergency Authority and Government
concern regarding the volume or timing of a particular queue announcement impacting on call handling, this is fed into the particular Emergency Service. Paragraph 15 of my statement refers.
4. Finally, it is understood the Critical Call Process was not used on the call in question. A concern that I have is whether BT has an effective process in place to identify a critical call and prioritise it accordingly
BT has a Critical Call Process to identify a critical call where the BT Operator hears speech or sound that indicate an imminent or immediate risk to life. BT has agreed with Ambulance Trusts nationally which category of calls they consider critical and would trigger the Critical Call Process if the BT Operator were to hear speech or sound to suggest those scenarios. Paragraphs 3, 4 and 10 of my statement refer. Distress alone is not an agreed trigger for the Critical Control Process. Critical calls are prioritised by connection to the Trust secondary line which is at the head of their queue. Paragraph 7 of my statement refers. If the Trust does not quickly answer, the BT Operator will connect to another Trust secondary line. BT also hold a Critical Contact number for each Trust as documented in section
4.1 of the PECS included in Exhibit KS1.
I hope that this information provides the required clarification on the points raised.
Report Sections
Investigation and Inquest
On 2nd December 2024 at Oxfordshire Coroner’s Court I conducted the inquest into the sad death of Wyllow-Raine Swinburn, aged 3 days, at the John Radcliffe Hospital Oxford on 30th September 2022. Her cause of death was found to be congenital hyperinsulinism and hypoglycaemia leading to a cardiac arrest.
I returned a Narrative Conclusion as follows;
Wyllow-Raine Swinburn was born on 27th September 2022 at the John Radcliffe Hospital, Oxford. She was discharged on the evening of 29th September 2022 with no significant concerns and went home with her mother to , Didcot. She fed that evening and in the early hours. She stirred again at approximately 04:00 hours and her mother attempted to feed her but at approximately 04:36 hours her movements suddenly stopped, and she became unresponsive. An ambulance was called at 04:38 hours, but the call did not connect to an ambulance service until 04:45 hours when instruction on CPR was given and followed. The first paramedic arrived at approximately 05:09 hours and took over CPR, assisted by other ambulance personnel, who arrived a few minutes later.
There was helpful evidence in the form of statements from SCAS staff including , who also gave oral evidence. South Central Ambulance Service (SCAS) were legally represented and provided with a copy of the inquest file.
I returned a Narrative Conclusion as follows;
Wyllow-Raine Swinburn was born on 27th September 2022 at the John Radcliffe Hospital, Oxford. She was discharged on the evening of 29th September 2022 with no significant concerns and went home with her mother to , Didcot. She fed that evening and in the early hours. She stirred again at approximately 04:00 hours and her mother attempted to feed her but at approximately 04:36 hours her movements suddenly stopped, and she became unresponsive. An ambulance was called at 04:38 hours, but the call did not connect to an ambulance service until 04:45 hours when instruction on CPR was given and followed. The first paramedic arrived at approximately 05:09 hours and took over CPR, assisted by other ambulance personnel, who arrived a few minutes later.
There was helpful evidence in the form of statements from SCAS staff including , who also gave oral evidence. South Central Ambulance Service (SCAS) were legally represented and provided with a copy of the inquest file.
Circumstances of the Death
The brief circumstances of Wyllow-Raine’s sad death are set out in the Narrative Conclusion above. It will be seen there was a delay of 7 minutes in the 999 call being connected to an ambulance service, initially East Midlands and then SCAS. The response time for the first paramedic to attend was 31 minutes. She died in hospital on 30th September 2022.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.