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| Version 1 | Version 2 |
|---|---|
| West Midlands Ambulance Service mistakes caused serious incidents | West Midlands Ambulance Service mistakes caused serious incidents |
| (2 months later) | |
| Naomi Rees-Issett says she had to fight to have her son's death to be investigated by the ambulance service | Naomi Rees-Issett says she had to fight to have her son's death to be investigated by the ambulance service |
| More than half of all serious incidents where patients came to harm involving West Midlands Ambulance Service were due to clinical errors. | More than half of all serious incidents where patients came to harm involving West Midlands Ambulance Service were due to clinical errors. |
| A trust audit found choking management, cardiac arrests and inappropriate patient discharges as themes. | A trust audit found choking management, cardiac arrests and inappropriate patient discharges as themes. |
| It also noted a decision to close all community ambulance stations was taken without first doing a full risk assessment of the impact on safety. | It also noted a decision to close all community ambulance stations was taken without first doing a full risk assessment of the impact on safety. |
| Serious incidents have reduced as a result of action taken since. | Serious incidents have reduced as a result of action taken since. |
| West Midlands Ambulance Service (WMAS) also said its ambulance station closure programme had been independently validated. | West Midlands Ambulance Service (WMAS) also said its ambulance station closure programme had been independently validated. |
| After the number of serious incidents increased from 138 in 2021-22 to 327 in 2022-23, an audit by WMAS found 53% were due to mistakes with their treatment. | After the number of serious incidents increased from 138 in 2021-22 to 327 in 2022-23, an audit by WMAS found 53% were due to mistakes with their treatment. |
| The Care Quality Commission (CQC) watchdog said it was currently reviewing serious incidents at the ambulance trust and would carry out an inspection in due course. | The Care Quality Commission (CQC) watchdog said it was currently reviewing serious incidents at the ambulance trust and would carry out an inspection in due course. |
| A situation where a person comes to significant harm in care is identified as a serious clinical incident. | A situation where a person comes to significant harm in care is identified as a serious clinical incident. |
| Sources say the trust also delayed completing investigations into 5,000 incidents, some of which involved patients. | |
| Mistakes accounted for 53% of serious incidents in 2022-2023 | Mistakes accounted for 53% of serious incidents in 2022-2023 |
| Naomi Rees-Issett's 18-year-old son Jamie died after going into cardiac arrest in Rugby and waiting more than 17 minutes for an ambulance in January 2022. | Naomi Rees-Issett's 18-year-old son Jamie died after going into cardiac arrest in Rugby and waiting more than 17 minutes for an ambulance in January 2022. |
| Mrs Rees-Issett says she had to fight for an investigation by the ambulance service. | Mrs Rees-Issett says she had to fight for an investigation by the ambulance service. |
| "I know how long we waited and how hard we had to try to get any form of investigation, so this does not surprise me at all," she said. | "I know how long we waited and how hard we had to try to get any form of investigation, so this does not surprise me at all," she said. |
| In this instance, WMAS said, due to crews tied up outside hospitals, it had not had an ambulance that could have got there sooner. | In this instance, WMAS said, due to crews tied up outside hospitals, it had not had an ambulance that could have got there sooner. |
| It said a huge percentage of its serious incidents were caused by ambulances being delayed outside hospitals while paramedics waited to hand over patients, which then impacted on other aspects of its service. | It said a huge percentage of its serious incidents were caused by ambulances being delayed outside hospitals while paramedics waited to hand over patients, which then impacted on other aspects of its service. |
| "When we realised what was happening, we put in place additional checks. As a result, we have seen the number of serious incidents come down," it said. | "When we realised what was happening, we put in place additional checks. As a result, we have seen the number of serious incidents come down," it said. |
| WMAS said serious incidents had reduced as a result of action taken | WMAS said serious incidents had reduced as a result of action taken |
| There were concerns about staff following the appropriate protocols. | There were concerns about staff following the appropriate protocols. |
| "The trust looked at what was going on and took necessary action to remedy the situation," said communications director Murray MacGregor. | "The trust looked at what was going on and took necessary action to remedy the situation," said communications director Murray MacGregor. |
| Report finds ambulance whistle-blowers stifled | Report finds ambulance whistle-blowers stifled |
| Ambulance service boss warns of possible collapse | Ambulance service boss warns of possible collapse |
| Ambulance recruitment day response 'fantastic' | Ambulance recruitment day response 'fantastic' |
| West Midlands Ambulance Service says it is taking on 10 extra staff to look into patient safety incidents. | West Midlands Ambulance Service says it is taking on 10 extra staff to look into patient safety incidents. |
| With regard to the backlog of 5,000 cases, the trust said it had a new system in place. | With regard to the backlog of 5,000 cases, the trust said it had a new system in place. |
| "As part of that, we have identified a number of incidents that were not investigated as they should be. We have now examined all of those cases," Mr MacGregor said. | "As part of that, we have identified a number of incidents that were not investigated as they should be. We have now examined all of those cases," Mr MacGregor said. |
| "Three resulted in serious incidents being identified and they are being investigated." | "Three resulted in serious incidents being identified and they are being investigated." |
| WMAS said a huge percentage of its serious incidents were caused by ambulances being delayed outside hospitals | WMAS said a huge percentage of its serious incidents were caused by ambulances being delayed outside hospitals |
| In October 2021, months before Jamie Rees's death, a decision was taken to remove the community ambulance station in Rugby, along with ambulance stations across the region. | In October 2021, months before Jamie Rees's death, a decision was taken to remove the community ambulance station in Rugby, along with ambulance stations across the region. |
| The minutes of a quality assurance meeting in January, days after Jamie's death, show the decision was taken without a full risk assessment having been undertaken. | The minutes of a quality assurance meeting in January, days after Jamie's death, show the decision was taken without a full risk assessment having been undertaken. |
| The minutes reveal that Mark Docherty, the then nursing director, told the quality governance committee: "The process was slightly cart before the horse as the closures had happened before the quality impact assurance had been completed." | The minutes reveal that Mark Docherty, the then nursing director, told the quality governance committee: "The process was slightly cart before the horse as the closures had happened before the quality impact assurance had been completed." |
| Mr Docherty said he was not saying the Community Ambulance Service should go, but the trust did not have the resources to put into them. | Mr Docherty said he was not saying the Community Ambulance Service should go, but the trust did not have the resources to put into them. |
| Unite union representative Steve Thompson called the process "quite deplorable" and said: "We have let ourselves down badly as an organisation." | Unite union representative Steve Thompson called the process "quite deplorable" and said: "We have let ourselves down badly as an organisation." |
| WMAS director Mark Docherty said closures had happened before the likely impact had been fully assessed | WMAS director Mark Docherty said closures had happened before the likely impact had been fully assessed |
| Several councillors were elected to Evesham Town Council to fight the closure of their ambulance station. | Several councillors were elected to Evesham Town Council to fight the closure of their ambulance station. |
| They began a judicial review of the decision, but Judge Ian Dove refused them leave to appeal on the basis the changes did not materially impact the service they received. | They began a judicial review of the decision, but Judge Ian Dove refused them leave to appeal on the basis the changes did not materially impact the service they received. |
| Councillor Julie Haynes was shocked when told of Mr Docherty's comments about the quality impact assessment. | Councillor Julie Haynes was shocked when told of Mr Docherty's comments about the quality impact assessment. |
| She said: "I had never heard of that phrase [quality impact assurance]... and it makes me very sad indeed because I think that we could have won and then the town could have saved its ambulance service and I think that the judge might have taken us more seriously." | She said: "I had never heard of that phrase [quality impact assurance]... and it makes me very sad indeed because I think that we could have won and then the town could have saved its ambulance service and I think that the judge might have taken us more seriously." |
| Update 8 September 2023: This story has been amended to make clear the 5,000 incidents investigated did not all involve patient safety. | |
| Follow BBC West Midlands on Facebook, Twitter and Instagram. Send your story ideas to: newsonline.westmidlands@bbc.co.uk | Follow BBC West Midlands on Facebook, Twitter and Instagram. Send your story ideas to: newsonline.westmidlands@bbc.co.uk |
| Related Topics | Related Topics |
| Evesham | Evesham |
| West Midlands Ambulance Service | West Midlands Ambulance Service |
| NHS | NHS |
| Rugby | Rugby |