Ambulance service downgraded thousands of 999 calls without authorisation

Nearly 10,000 patients with potentially life-threatening conditions who needed an ambulance had longer wait times because the East of England Ambulance Service altered the code sets that designate the priority of calls, without authorisation.

The trust has released a report into how it altered 28 national code sets, which set the level of response times, on 18 December 2013 – against Department of Health guidelines.

Seven code sets were upgraded, meaning those calls would have been given a more urgent priority, while 21 were downgraded.

This meant callers had to wait longer for an ambulance response or no paramedic response at all, but received a telephone call instead.

The code sets remained changed until 22 February 2014, in which time the trust says 8,324 patients were affected by the rule changes – 57 of whom died.

The downgrading came about because of a decision made in June 2013 to review the coding of calls due to plans to upgrade to a newer version of their dispatch software.

Once the review was completed it was supposed to return to the EEAST’s Clinical Quality Safety Group for approval, but instead staff downgraded the call codes without approval from directors or the board as they wanted to implement the new system before the software update.

The head of the Isle of Wight Ambulance Trust, Chris Smith, looked into the incident, with the new report written by the trust’s interim head of quality governance, Emma de Carteret.

It says: “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”.

When the incident occurred the trust was in a period of change and without a chief executive, as the newly hired Anthony Marsh had 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.

Marsh was made aware of the code set changes in a staff meeting on 19 February 2014. On 22 February he reinstated the Department of Health approved code sets and ordered a full investigation into what happened.

A review of the downgrade and a survey of patients affected failed to reveal any harm.

"The harm analysis suggests that, whilst governance procedures were not followed for the alterations to code sets (priorities), the rationale behind the changes was likely to be correct," the report concluded.

Of the 57 patients who died during the period, 44 had a Do Not Resuscitate Order and 13 were expected deaths.

The investigation report has recommended that any future changes to priorities must be researched with patients in mind and must be signed off at Executive Management Board level.

It also recommended “greater board training, support and guidance for future executive appointments and senior members of the management team.”

Denise Burke, from the Act on Ambulances campaign and Labour’s parliamentary candidate for North Norfolk, said: “It 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.”

Trust chief executive Anthony Marsh said: “I was told about these changes during a meeting with staff on 19 February 2014 and immediately launched an investigation and ordered the reversal of the changes. Whilst these changes should not have been made in the way that they were, no harm was caused to patients and it had no impact on performance reporting. Since I took over we now have much stronger governance arrangements in place, alongside an experienced executive and non executive team.”

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