Emergency services related deaths

Concerns summary Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.

Concerns summary A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.

Concerns summary West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability and posing a risk to patient lives.

Concerns summary Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.

Concerns summary Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving treatment.

Concerns summary An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.

Concerns summary Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.

Concerns summary Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.

Concerns summary Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.

Concerns summary Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.

Concerns summary Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a missed opportunity to administer a potentially life-saving antidote.

Concerns summary Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact emergency services, missing critical reassessment opportunities.

Concerns summary National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.

Concerns summary Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical nature in specialist vascular knowledge.

Concerns summary A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.

Concerns summary Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support training, posing a significant risk of future deaths.

Concerns summary The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.

Concerns summary An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.

Concerns summary Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision of medical and psychiatric assistance for an overdose.

Concerns summary A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.

Concerns summary Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.

Concerns summary A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.

Concerns summary Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.

Concerns summary The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.

Concerns summary Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of geriatric specialists. Ambulance staff demonstrated inconsistent fall risk assessment and insufficient training.