East Midlands Ambulance Service

“MFT intends to formally communicate this to the external transport providers that support in the discharges of our patients”

“we have put in place processes to ensure that this does not happen again.”

“We are also reviewing our processes where a person is discharged from a Manchester hospital into an 'out of area' locality and if a safeguarding concern takes place on discharge”

“We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report”

“we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report”

“EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue as a safeguard to patients until the policy is received from Manchester Royal Infirmary.”

“the Trust takes all matters relating to patient safety extremely seriously. In particular, matters arising from Coroners' Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed by the Incident Review Group and Lessons Learned Group.”

“We have taken this call through NHS Pathways version 16 to try to identify the likely outcome had this version been in place at the time of the call. In version 16 the severely ill and new marks question has changed significantly. Firstly the 2 parts have now been split into separate questions. Due to concerns that the severely ill part of the question was too subjective this has been altered to”

“The EMAS emergency operations centre (EOC) has in place a structured triage and escalation system to ensure that patient safety is embedded across the call handling and dispatch systems.”

“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”

“EMAS has taken the CQC findings seriously and value the additional support from other NHS organisations following the CQC Quality Summit. With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS' immediate control.”

“In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices 1a and 1b).”

“A patient safety alert was issued on the 2 September 2014 by NHS England clearly sets out the resources available in the provision of a UK Sepsis clinical tool kit, but this has not be recognised or adopted by health care providers in this case.”

“Inadequate note was made of the number of different attendances Mrs [name redacted] had initiated despite previous good health, and there is no suggestion that she was a frequent attender or had ever sort medical attention inappropriately.”

“Service has made significant investment in both staff and vehicle resources since 2014 in both "frontline" staff who attend 999 calls but also in staffing within the emergency operations centre. This recruitment has been supported with investment in our education centres to facilitate training from Emergency Care Assistant, through Ambulance Technician and ultimately to Paramedic level. Staff work on allocated rota lines with a percentage (around 12% in Lincolnshire) working on relief where they can be”

“immediate action we will communicate with our lead commissioners to disseminate the following message to all GP's and Bed Bureau. If a patient's condition presents an immediate threat to life or relates to new symptoms of Stroke or Cardiac chest pain call 999 for an emergency response”