Barbara Patterson
This report repeats 1 earlier warning, and was raised again 15 times later. See the linked reports.
The coroner's concerns
1. lack of timely CPR advice
“The failure by the Call Handler to give timely advice in respect of CPR”
2. Pathways system does not advise non-clinical call handlers to issue CPR advice for agonal breathing
“During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non Clinical call handlers to issue CPR advice unless a patient has stopped breathing”
3. dispatcher does not dispatch ambulance closer to location
“The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location”
4. ambulance arrival delayed beyond target
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes”
5. national shortage of paramedics
“During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East”
6. ambulance crews delayed at hospital handover
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
Linked reports
Earlier report
“The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.”
This report
“During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non Clinical call handlers to issue CPR advice unless a patient has stopped breathing.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
Later report
“Consideration should be given to strategies to improve handover times at hospitals.”
This report
“During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East”
Later report
“I was told there were still 32 paramedic vacancies to be filled a year on after [the deceased]'s death.”
This report
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”
Later report
“target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust's average response”
This report
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes”
Later report
“The inquest heard evidence that under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”
This report
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”
Later report
“had an ambulance for [the deceased] arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life”
This report
“The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location”
Later report
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“There was a significant delay in offloading patients at hospitals, which tied up resources and meant they were unable to respond to emergency calls.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“This delay being significantly contributed to by the handover delays in hospitals.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
Later report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”
This report
“ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
Later report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
This report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Responses
2015-0198-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action · September 2015
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
2015-0198-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · early 2014
“The Pathways system piloted in the North East has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing. Although this fault was pointed out to Pathways by NEAS NHS Trust manager before the latest update of the system (early 2014), Pathways refused to amend the system. The fault remains in place.”
2015-0198-Response-by-North-East-Ambulance-Service-NHS-Trust.pdf ↗· North East Ambulance Service NHS Foundation Trust