Barbara Hollis
26 Aug 2022 · Coroner Jaqueline Lake · Norfolk
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed ambulance response
“EEAST were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect.”
2. inadequate response time
“The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes”
3. delayed ambulance arrival
“At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours”
4. resource unavailability
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
5. potential future deaths
“It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
This report
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Closely relatedConfidence 0.85 · high
Earlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
This report
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Closely relatedConfidence 0.90 · high
This report
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Later report
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Responses
2022-0264-Response-from-East-of-England-Ambulance-Service.pdf ↗· East of England Ambulance Service
Stated action
“The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
2022-0264-Response-from-Spire-Norwich-Hospital.pdf ↗· East of England Ambulance Service
Stated action
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”