East of England Ambulance Service releases full report into downgrading of thousands of 999 calls
The region’s ambulance service on Monday released the full report into why thousands of calls at the trust were downgraded - potentially leading to slower response times and less urgent care for patients in life-threatening situations.
On Thursday, the East of England Ambulance Service Trust (EEAST) published a two-page summary of a much-delayed report into how and why more than 8,000 emergency calls were re-graded between December 2013 and February 2014.
The full report details how a small group of staff downgraded thousands of calls, against Department of Health guidelines, without telling the board or management.
The downgrading came about because of a decision made in June 2013 by the EEAST’s clinical quality safety group to review the coding of calls.
They wanted to review the call codes as they were upgrading to a newer version of their dispatch system software.
Once the review was completed, it was supposed to return to the EEAST’s clinical quality safety group for approval.
But this did not happen. Instead, staff downgraded the call codes, without full, prior approval from directors, because they were in a rush ahead of the software update.
“In spite of staff concern, no adverse incident report was submitted by staff in relation to the code set changes. This led to the changes being in place for over two months without recognition,” the report said.
This was put down to the “instability” of the organisation which led to “limited strategic oversight”.
In December 2013 the trust’s leadership was in an interim period, with the new chief executive, Anthony Marsh, yet to start.
“Staff involved in the decision to amend the triage code sets were in post on an interim basis and had received limited development in role,” the report added.
The trust’s interim director of clinical quality at the time has since left his post.
The ambulance report did not look at all 8,300 calls affected over the two months when call codes were changed because of “the high number of incidents involved”.
Instead, 3,600 of the cases have been reviewed and no harm to patients was identified because of the downgrading, but 57 people died during that two-month period.
Denise Burke, from the Act on Ambulances campaign and Labour’s parliamentary candidate for North Norfolk, said: “It is beggars belief that this serious incident happened at the trust.
“It was seven months in the planning and then went on for more than two months without any senior manager or board member raising concerns. Someone must have known what was going on and we need to be told who.
“What is most shocking is the way patients who were near the end of life were treated. The report reveals that 57 end of life care patients died during the two month period and we need to know whether their death was accelerated by the downgrading of the calls.”
The incident was investigated by the head of the Isle of Wight Ambulance Trust, Chris Smith, but the report was authored by the trust’s interim head of quality governance.