NEAS Review: The patients let down by the North East Ambulance Service
An independent review of the North East Ambulance Service has explored how it covered up failings in a number of patient deaths.
The review was carried out following allegations that staff had covered up errors and withheld evidence from coroners.
The report, published on Wednesday 12 July, also looked at how relatives were not always given a full explanation of the death of loved one if mistakes were made.
Retired hospital boss Dame Marianne Griffiths looked at the cases of four patients whose deaths were considered as part of the review.
The four patients, labelled A to D, were included in the 97-page report which includes harrowing details about NEAS failings when responding to serious incidents.
In the review, all four patients were anonymised to protect their identities.
NEAS Chief Executive Helen Ray responds to the content of the review
Patient A - Quinn Milburn-Beadle
What happened?
Quinn Milburn-Beadle, a teenager from County Durham, died in December 2018 after taking her own life.
The ambulance service was called to assist after the 17-year-old was found at her home in Shildon.
Paramedic Gavin Wood was the first on the scene and declared her dead without administering CPR or attempting to provide advanced life support.
His actions were reported by the second paramedic team to arrive but the Miss Milburn-Beadle's family were not made aware of the concerns or that an investigation was to be conducted.
At the inquest into Miss Milburn-Beadle's death, it became clear that the family had not received all of the information relevant to the case.
It was only at the hearing that they received all the papers from the investigation and, as a result, the coroner was not happy to make a conclusion on the incident until it was reviewed by an expert witness, adjourning the inquest from April to August.
The paramedic's actions as well as NEAS communication and governance were major points of contention for the family and were each covered in the review.
What went wrong
Before the review, there were three different reports on the incident. The first conclusion from the original investigation found that national guidelines had not been followed when declaring Miss Milburn-Beadle dead and advanced life support should have been provided.
However, the report was then altered by the NEAS strategy group. While it still found that national guidelines had not been followed, it deemed that it was right not to provide advanced life support.
This went against the conclusion made by the expert witness at the inquest into Miss Milburn-Beadle's death. They found that the paramedic should have continued resuscitation efforts and transported her to a hospital. While they still felt the teenager would not have survived, the failure to act made her death a certainty.
However, not being given the full picture at the first possible opportunity made things considerably more difficult for her family as they tried to come to terms with her death.
What the review said
The review offered a scathing assessment of the actions of the NEAS when dealing with the case.
Life-saving assistance should have continued to be given to Miss Milburn-Beadle while it could not support the decision to alter parts of the first report.
NEAS governance was found to be poor with not enough accountability during the original investigation while coronial and communication processes were not followed.
The result had a "devastating" impact on Miss Milburn-Beadle's family who do not believe NEAS were acting in an open and transparent manner. Their son Dylan, has since ended his own life and the family believe his sister's death and the way it was handled was a major contributing factor.
Her parents, Tracey and David described the report as a "whitewash".
Patient B
What happened?
Patient B was a 62-year-old man who suffered from a respiratory illness, requiring a 24-hour oxygen supply.
He dialled 999 on 14 March 2019, suffering from shortness of breath after a power cut had disrupted his oxygen supply.
The nearest ambulance was just three minutes away but it got stuck inside the station when the power cut prevented the gates from opening. No one onsite knew how to operate the manual override.
A second crew was allocated but they stopped to refuel on route and were further delayed when they struggled to locate the safe key to enter the property.
By the time they entered, 37 minutes after the original call, the patient had died.
What went wrong?
The failure to open the gates, stopping for fuel and the struggle to find the key all contributed to the delay.
The incident was initially categorised as "low harm" but his family said it should have been treated more seriously.
The team responded within the 40 minutes target for a category two call.
This meant that the delays and the reasons for them did not have to be communicated to the family or the coroner and were not included until the coronial process was independently reviewed in May 2020.
The family only found out about the delays via a whistle-blower.
What the review said
The review found there were mistakes for each of the three major delays. There was no real process in place to override the gates and staff had not received any training.
It also found that there was no need to refuel the ambulance as there was still 29 litres in the tank. The driver was a newly qualified paramedic but were not corrected by their crew mate.
The call handler should also have tried to extract more details about the location of the safety key when on the call after being solely told it was just “up the drive.”
The review also stated that the incident should have been classed more seriously. Doing so would have meant that details about the issues would have been passed on to the family sooner, helping them to come to terms with what had happened.
Patient C
What happened?
Patient C was a 62-year-old man who called 999 after falling on a wooden washing basket, suffering a suspected punctured lung and heavy bleeding.
The incident on 19 December 2019 was classed as a category two call meaning the response time should have been 40 minutes.
However, it took one hour and eight minutes for the ambulance to arrive despite four further calls stressing how the patient's condition was deteriorating.
The third call detailed how he was becoming drowsy and going into shock. A fourth from the man's niece, who was also a nurse, stressed that her uncle was dying.
A clinician eventually called 59 mins after the ambulance service was first alerted and upgraded the incident to a category one call.
However, by the time ambulance crews arrived it was too late to save him despite more than an hour of life-saving efforts at the scene.
What went wrong?
The response time for a category two call was not met. Had the ambulance arrived within the targeted 40 minutes he would have had a much higher chance of survival.
The processes to escalate the call also failed. The incident should have been upgraded following the third call but it did not happen, despite the family's best efforts.
There were also further delays once the clinician called as they were unable to access patient C's notes.
There were also issues afterwards with the family's distress worsened by some of the interactions with NEAS staff.
What the review said
The review found that a large number of 999 calls, a lack of staff and the number of ambulances tied up in hospitals all contributed to the slow response time.
It also found that the call should have been progressed to a clinician sooner, especially given the reports were coming from a qualified nurse. The review also struggled to understand why call handlers did not recognise the speed of his deterioration.
The review also acknowledged the hurt caused to the family in their communications with NEAS after the incident with a full apology given.
The family continue to suffer from ongoing distress from the incident. Patient C's sister lived next door and had to look at the daily reminder of a blood stain on the carpet outside, eventually causing her to move to a different property.
Patient D
What happened?
Patient D was a 52-year-old woman who called 999 after suffering from breathing difficulties and pain in her arm and shoulder.
The incident on 30 November 2019 was classed as a category two call, but like in the case of Patient C, the 40-minute target time was not met and they arrived one hour and 14 minutes later.
In a second call, received almost 30 mins after the first, she stressed that she was also suffering tightness in her chest but in remained category two.
Patient D was declared dead 13 minutes after the ambulance crew arrived.
The family were left with questions about why it took so long and whether an early response would have made a difference.
What went wrong
Once again the response time for a category two call was not met.
An ambulance had been assigned 44 minutes after the call but was reassigned to a category one incident shortly afterwards increasing the delay.
What the review found
The review found that the delay was once again due to high demand outstripping the number of available resources.
It was also concluded by the NEAS, the coroner and family that it was highly unlikely Patient D would have survived if an ambulance had arrived earlier as she had suffered a significant heart blockage.
Her family were satisfied by the response received and do not want the issue to go any further.
Following publication of the report, NEAS chief executive Helen Ray said: “Firstly, I would like to say how sorry I am for any distress caused to the families for mistakes made in the past.
“Each family has received an unreserved apology from me on behalf of the trust.
“There were flaws in our processes and these have now either been addressed or are being resolved at pace.”
The report agreed that measures have now been taken and a new leadership team is in place.
Ms Ray added: “We have strengthened the governance, systems and processes relating to investigations and coronial reports; and continue to monitor these to ensure the lessons have been learned.”
"The action we have taken is also recognised by the Care Quality Commission, who last week said we have begun to make the improvements that address their concerns.
“However, there is more to do so the public can receive the best possible care.”
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