Emergency services related deaths

Concerns summary The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged immobility.

Concerns summary The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.

Concerns summary Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.

Concerns summary An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.

Concerns summary Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to significant delays in patient care. The lack of police-to-hospital conveyance options for urgent cases is also a concern.

Concerns summary Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.

Concerns summary Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.

Concerns summary Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.

Concerns summary Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in call handling.

Concerns summary Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response capacity.

Concerns summary Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.

Concerns summary A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks for patients.

Concerns summary Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.

Concerns summary Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed PFD reports.

Concerns summary Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort to risky mitigating measures like recommending self-conveyance.

Concerns summary Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.

Concerns summary A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.

Concerns summary NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.

Concerns summary Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated by the absence of an out-of-hours falls service.

Concerns summary Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.

Concerns summary Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.

Concerns summary The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.

Concerns summary An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.

Concerns summary Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.

Concerns summary Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.