Recurance · prevention of future deaths reports
Pre-inquest brief
Simultaneous ambulance crew meal breaks reduce vehicle availability
The earlier warning
Kathryn Richmond · 17 Nov 2017 · Rachael Griffin, Dorset
“Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts, there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time.”
judiciary.uk/prevention-of-future-death-reports/kathryn-richmond
What was promised
Stated action 1 · response to Kathryn Richmond (17 Nov 2017) · stated timescale: none stated
“The AACE will ensure that the National Directors of Operations Group is made aware of your concerns and remind them of the need to regularly review rostering arrangements.”
judiciary.uk/…/2017-0401-Response-by-Department-of-Health.pdf
What recurred
- 12 Sept 2019 · William Oliver · Joanne Kearsley · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Kathryn Richmond · 17 Nov 2017
“Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts, there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time.”
Later · William Oliver · 12 Sept 2019
“each crew has to take a 30 minute meal break within their meal break window (this being three hours after their shift starts). If the crews reach the end of their meal break window without having taken a break they are automatically stood down and are unavailable to allocate calls to”
What happened next
No web check of the stated actions has been published for this chain.