Patient safety


‘Secret protocol’ meant SECAmb ignored urgent 111 calls

NHS 111 helpline calls were not properly responded to at South East Coast Ambulance Trust (SECAmb) after the trust’s chief executive secretly ordered emergency calls to be downgraded, according to a leaked report.

The Daily Telegraph, which has seen the Monitor report into failings at the trust, said that the trust ordered a pilot scheme in 2014 where non-urgent ‘green’ calls were placed in automatic 10 minute queues to prioritise ambulance responses to ‘red’ calls.

But the report says that trust chief executive Paul Sutton secretly introduced a protocol to apply the queue to ‘red’ calls as well to allow the trust to meet performance targets.

A number of senior managers told the inquiry that they tried to protest the order, with one quoted as saying "an improper level of pressure was applied to certain individuals" who opposed it.

The protocol is thought to have led to 11 deaths in the trust’s target area of Sussex, Kent, Surrey and North East Hampshire, including a 60-year-old man who waited 35 minutes for an ambulance despite suffering a cardiac arrest.

Neither patients or 111 handlers knew about the protocol, and local commissioning groups only knew after they were alerted by a whistleblower.

The report concludes: “Our overall conclusion from this review is that there were a number of fundamental failings in governance at the trust which resulted in the implementation of a high risk and sensitive project without adequate clinical assessment or appraisal by the board, commissioners or the 111 service.

"The CEO made the ultimate decision to proceed with the pilot and played a critical leadership role throughout.”

The report is the latest in a series of criticisms of 111 helplines around the country, after Professor Neena Modi, president of the Royal College of Paediatrics and Child Health said that it was “uncertain” whether the service was capable of diagnosing child patients.

In September 2014 one-year-old William Mead died of sepsis despite his parents contacting 111 and GPs.

A Monitor spokesperson said: “As part of our ongoing regulatory action, we asked South East Coast Ambulance NHS Foundation Trust to commission a detailed review of the project, including the way decisions were made about it. This review is yet to be published. We will provide an update on our regulatory response in due course.

 “We also asked the trust to carry out a separate independent review to identify the impact the project had on patients. This review has begun and is due to complete later this year. The impact on patients cannot be confirmed until it concludes. However, in the work carried out so far no cases of patient harm that were not previously identified have come to light.”

NHE contacted SECamb for comment but they did not respond at the time of publication.

 UPDATE 2.30pm

A SECamb spokesperson said: “South East Coast Ambulance Service NHS Foundation Trust has refuted claims made in today’s Daily Telegraph following its article based on a leaked, draft report.

“The article refers to a report undertaken by Deloitte which was not looking at patient impact but at the decision-making and governance around the implementation of the pilot, and what recommendations can be made for SECAmb’s governance processes in light of this.

“As we have stated previously, the separate, independent, clinically-led patient impact review, being carried out as part of the Monitor undertakings, is currently underway and is yet to be concluded.

“Until it does it is inaccurate and completely misleading to attribute or imply any harm or deaths to the pilot.

“We will publish the findings of the patient impact review as soon as it is complete.

“However, in the preliminary work to date, no clear indications of patient harm have been identified. Indeed, the review has identified a number of seriously ill patients who received an improved response due to earlier clinical intervention as a consequence of the pilot.”


Katherine Murphy   29/02/2016 at 17:43

This confirms our previous serious concerns here at the Patients Association about secretive decision-making and cover-up at SECamb. Everyone working in the NHS should be making the right decisions based on the best way to protect peoples’ lives and their health. The public especially expects that those in leadership positions are held accountable for their actions. Any decision that downgrades urgent category ambulance calls in order to massage performance targets is deplorable, and undermines the confidence that the public places in NHS leaders. If Mr. Sutton chose to ignore colleagues’ concerns about the dangerous consequences of downgrading emergency ambulance calls, this suggests exceptionally poor decision making by someone in a key leadership role. Such conduct would fall far short of the standards that the public expects. There are also important questions for other senior staff in the Trust to answer. This issue goes back to 2014 and should have been resolved long ago, rather than being dragged out through leaked reports. The Trust should apologise and the NHS should ensure this never happens again.

Anon   29/02/2016 at 19:11

I cannot give details for obvious reasons. I was a senior training manager with SECAmb until I was 'constructively' made redundant due to my challenging SECAmbs inability to follow policy and procedure. I used to have to report to the commissioners regarding training figures - training was stopped by a senior manager.

Anon   29/02/2016 at 19:44

I too worked for SECAMB and the practice mentioned didn't only happen in the months mentioned. There were other similar practices that happened through my 6 year employment with them that caused a lot of unease but it was very hard to go against what you were being told to do without being told you were doing wrong and singling yourself out for harassment!

Anon   29/02/2016 at 19:58

Secamb is not the only service fiddling the response times, it's endemic throughout the uk, and the government seems to turn a blind eye! otherwise they would need invest heavily so that the ambulance trusts can keep up with the ever increasing demands placed on them

Anon   01/03/2016 at 01:46

With the Chief Executive, Mr Sutton and his side kick, Andrew Newton both implicated and up to their necks in this, being registered Paramedics themselves, I hope that they have self reported to the HCPC or someone will do it for them...

Another Disgruntled Staff Member. A.   01/03/2016 at 09:22

I have been working for secamb for 13 years. sorry previously was sussex ambulance. I am sadly now overworked and fed up with being bested whenever I am at work Instead of doctoring figures and coming g up with silly schemes maybe all the managers that swan around with blue lights on their cars could help out with the incoming calls. I regularly see managers moaning about targets. But these 'response capable' managers do not help. Change is needed.

Stuff   01/03/2016 at 10:40

We at 111 did know...

Rob   01/03/2016 at 21:13

What is NOT being mentioned is that there are not the ambulance resources to meet the response times, and the service would be 'fined' for not meeting targets, no matter how unrealistic. In my opinion, most front-line services are forced to cheat to keep running. Please think hard before condemning an otherwise excellent CEO and Chief Paramedic!

Anon   03/03/2016 at 10:58

Rob, so because all Cheifs fiddle the books it's not ok to condemn Sutton et al?....all of the Chiefs are equally to blame, they know they are under resourced and could speak up publicly but they don't, why is that?...could it be the several hundred thousand a year salary and bonuses they're all on!? Sutton is a career man like any other CEO, he's not there for the staff or patients, he's there for the 100k+ salary he draws and the 30k rise he got last year, I didn't get a rise and I haven't committed fraud....where's the fairness in that? Sutton is in the job for the comfortable position that awaits him at Whitehall/DoH, hopefully this scuppers that plan. Chiefs should be paid slightly more than a CTL/PP/COM type position then you'd actually get people in position who want to do the job not just get paid a packet and secondly (and most importantly) you'd get Chiefs who could speak out because there'd be no fear of losing their six figure job, if they rocked the boat (as they should) they'd get removed from post and could go back to being a Paramedic with no great loss of salary. Anyway, the Telegraph seem to be like a dog with a bone over this, can't wait to see who loses their job first, as someone else suggested....why aren't the HCPC involved yet?

Secamb Employee   18/03/2016 at 22:32

All managers above band 7, in post when the 2006 merger took place need to go if SECAmb is ever going to get rid of its organisational corrupt and bullying culture. There is much more that will never come to the surface as no one knows where to look. Sutton should do the honourable thing and resign today along with the rest of the trust board and band 8 managers as a start.

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