Investigation into 111 scandal branded a 'whitewash' after it fails to establish who was responsible
Patients groups and safety campaigners have criticised an NHS investigation which found up to 20,000 patients were subjected to deliberate delays under a secret policy - but failed to work out who was responsible for the scandal
An investigation into deliberate ambulance delays has been branded a "whitewash" after it failed to establish who is to blame for a major NHS scandal.
An eight-day-old baby and a patient suffering an obvious stroke were among up to 20,000 patients whose ambulances were delayed as part of a secret policy by South East Coast Ambulance Service NHS Foundation Trust.
For two months, “life threatening” cases referred to them from the 111 phone line were routinely forced to wait twice as long for an ambulance.
The secrecy meant that 111 call handlers assured patients in 'life-threatening' situations that an ambulance was on its way, with no idea that it was not.
NHS England on Thursday published the findings of its investigation into the matter, the findings of which were revealed by the Telegraph earlier this week.
The report was unable to establish which senior managers were responsible for the secret project, and how it came to be hidden from the trust’s medical director, non-executives, and the public.
Under NHS rules, calls designated as “life-threatening” are supposed to receive an ambulance response within eight minutes regardless of whether the caller dials 999 or the non-emergency 111 line. The target is to achieve this in 75 per cent of cases.
But the ambulance trust “unilaterally” invented its own system resulting in the routine downgrading of thousands of 111 calls, which were held in a special queue to be reassessed, with ambulances either cancelled or delayed for up to 10 minutes more.
“They were warned again and again about the risks this was posing to patients.”
The scheme was introduced by a group which was established by Paul Sutton, the trust’s chief executive, and overseen by at least four executives, but health officials could not work out who was responsible for the scheme.
"Because of the lack of documentation and the lack of information provided at interview, we have not been able to understand who made certain decisions or if they were issues that had been considered," the report concluded.
It was only when a whistleblower contacted NHS organisations responsible for monitoring safety that the scheme was aborted.
Katherine Murphy, chief executive of the Patients Association, said: "The findings of this report are very damning and paint a worrying picture.
"It is unacceptable for NHS England to say they cannot identify who gave the instructions to downgrade calls to 111 services in the South East. These decisions placed the public at risk and their actions were completely inexcusable.
"This is a whitewash and a major scandal.”
Surveillance of the scheme was so poor that it was impossible to work out whether patients were harmed by the delays, the report found.
Regulators have ordered a further independent investigation to establish how many patients were affected by it.
Cases placed in the queue included an eight day old baby, whose “clinical outcome” was not recorded, and a 60 year old man, who was suffering clear signs of a cardiac arrest but was pronounced dead soon after a 40 minute wait for an ambulance.
Peter Walsh, chief executive of patient safety charity Action against Medical Accidents said: "It's unacceptable that after an investigation of several months into a major scandal we are now none the wiser about who was responsible."
"I don't find it credible that neither the ambulance trust nor NHS England seem able to establish who took the critical decisions here."
A spokesman for NHS England South said: "The report makes clear that this project was initiated entirely within South East Coast Ambulance Service and resulted in changes to the handling of calls within the 999 service, not the 111 service.
"The regulator, Monitor, will oversee the next steps with the trust."
Paul Sutton, trust chief executive said: "Patient safety is fundamental to what we do.
"As paramedics, we come to work to save lives and we would never do anything to deliberately put patients at risk.
"We understand the concerns that the public have and wish to reassure people that we work constantly to provide the safest service possible.
"We recognise that the proper processes were not fully followed in setting up the project and we do apologise for this.”
The policy affecting thousands of calls was launched without the knowledge of 111 staff, board non-executives, the medical director or local commissioners of services, the report found.
• Patients with life-threatening conditions can wait twice as long for ambulance because they called 111
The secrecy meant that 111 call handlers assured patients in “life-threatening” situations that an ambulance was on its way, with no idea that it was not.
Instead, paramedics with just one day’s training in call-handling, were ordered to phone thousands of cases back to see if ambulances were really needed.
As a result, life-saving cases forced to wait up 18 minutes, were still counted as hitting the eight-minute target, while non-life threatening cases were given an extra 20 minutes.
Because the 111 staff referring the calls were never told about the system, many remained on the phone to monitor patients – blocking the line for the assessment call.
Those who should have been in charge of surveillance were not notified, with incidents only reviewed retrospectively by an administrator with no clinical background, it says.
The NHS England report examined seven “serious incidents” including five deaths.
However it says such cases are an unreliable way to assess safety, as they are usually under-reported.
"Not enough work has been done to identify whether patients were harmed as a result of the project"
A Monitor spokesman
• "There was no transparency with the public, as they were not told their call was going into a queue. They thought an ambulance was on its way when this was not true.
• This organisation potentially put the public at risk by changing nationally agreed operating standards with a project that had no evaluation built into its design.
• The governance structures that the Trust had in place were not followed. Whether or not this was intentional we have not been able to answer.
• The risks of the project were either not recognised or were ignored.
• Key staff were not consulted during the design and implementation of this project.
• The project was overseen by at least 4 Executives, who had a responsibility to have worked to the governance policies of the organisation.
• Serious Incidents were not identified, as the clinical risk system had no clinical input and key people within the department were unaware of the R3/G5 call partition."
The trust's efforts to check whether harm was done to patients were neither "appopriate" nor safe, it concludes.
This report speaks for itself; the NHS prepared a secret report which we only got hold of because it was leaked.
The report fails to tell us who was responsible for the scandal because the executives at the trust wouldn't tell them and because they didn't keep any records.
To me this seems like fraud - a job for the Police.
After all there's every reason to believe that people died as a result.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutthenhs.blogspot.com
Contact me; neilwithpromisestokeep@gmail.com
This report speaks for itself; the NHS prepared a secret report which we only got hold of because it was leaked.
The report fails to tell us who was responsible for the scandal because the executives at the trust wouldn't tell them and because they didn't keep any records.
To me this seems like fraud - a job for the Police.
After all there's every reason to believe that people died as a result.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutthenhs.blogspot.com
Contact me; neilwithpromisestokeep@gmail.com
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