Emergency services related deaths

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 An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of future deaths from prolonged lying and related injuries.

Concerns summary Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.

Concerns summary Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.

Concerns summary Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.

Concerns summary Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical deterioration in a patient's condition while awaiting transport.

Concerns summary Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of consultant midwives providing obstetric support across ambulance services.

Concerns summary The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.

Concerns summary Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.

Concerns summary Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

Concerns summary CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a need for clearer guidance on managing such scenarios.

Concerns summary A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.

Concerns summary There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.

Concerns summary Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.

Concerns summary A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full assessment, indicating a need for procedure review and revision.

Concerns summary Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were not integrated into the call handling system, and there was no automatic flagging for medical risks.

Concerns summary Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.

Concerns summary Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.

Concerns summary Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained health advisors who inadequately considered reported symptoms of a medical emergency.

Concerns summary An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.

Concerns summary NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.

Concerns summary The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.

Concerns summary The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.

Concerns summary The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical treatment.

Concerns summary National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through triage are hampered by insufficient resources.