North East Ambulance Service NHS Foundation Trust: Independent Review

Following a request by the Department of Health and Social Care, in May 2022, NHS England commissioned an independent review into concerns raised about compliance with coronial processes at North East Ambulance Service NHS Foundation Trust. Today, NHS England published the findings from this review.

I am grateful to Dame Marianne Griffiths for chairing this review and for the work she and her team have undertaken into investigating this important issue. The review was tasked with examining patient safety and governance processes at the trust which included consideration of previous investigations and reports on this matter. I am grateful to everyone who contributed to this review—the families and the staff—whose participation will enable lessons to be learnt.

The review found that significant leadership, cultural and behaviour issues contributed to the overall failings experienced by the families. For example, appropriate documentation was not provided to HM Coroners and, when submitted as part of the coronial process, documents had been amended to downgrade a serious incident into an event needing lesser scrutiny. This review makes 18 recommendations which cover governance, leadership, culture, and commissioning. The report has been published on NHS England’s website and is available here: https://www.england.nhs.uk/north-east-yorkshire/our-work/publications/ind-investigation-reports/

In the last decade, the Government have introduced substantial measures to reduce harm to patients, including a statutory duty of candour, legal protections for whistle-blowers, medical examiners across the NHS and legislation to establish the Health Services Safety Investigations Body. It is important that the right processes are put in place by trusts to make sure safeguards are properly implemented and there is continuous learning.

NHS England has also introduced a patient safety strategy which sets out how the NHS will support staff and providers to share safety insight and empower people—patients and staff—with the skills, confidence and mechanisms to improve safety. I also welcome the National Guardian Office’s review, published in February, into speaking up in ambulance trusts to ensure that ambulance services are a safe place to work, and staff feel confident and supported when issues need to be raised. Action includes the NHS launching an independent review into broader cultural issues in ambulance trusts.

Ambulance services are receiving £200 million of additional funding this year to grow capacity and improve response times, alongside 800 new ambulances, including specialist mental health ambulances. We have also made significant investment in the ambulance workforce, with the number of NHS ambulance staff and support staff increasing by over 40% since 2010.