Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Peter Scott · 26 May 2016 · Heidi Connor, Nottinghamshire
“I remain very concerned about resource issues for this ambulance service.”
What was promised
Stated action 1 · response to Peter Scott (26 May 2016) · stated timescale: none stated
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
Stated action 2 · response to David Briggs (1 Dec 2023) · stated timescale: 2023/24
“published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times”
judiciary.uk/…/2023-0506-Response-from-Department-of-Health-and…
Stated action 3 · response to Jade Griffiths-Jones (17 Apr 2024) · stated timescale: 2023/24
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
1 further stated action is listed on the full chain page.
What recurred
- 25 Jan 2023 · Rita Taylor · Tom Osborne · Identical hazard · confidence 0.90 (high)
- 9 Nov 2023 · Christopher Hart · Nigel Parsley · Identical hazard · confidence 0.90 (high)
- 1 Dec 2023 · David Briggs · Hannah Berry · Closely related · confidence 0.90 (high)
- 17 Apr 2024 · Jade Griffiths-Jones · Emma Brown · Identical hazard · confidence 0.92 (high)
- 4 Jul 2024 · Harry Dunn: Prevention of Future Deaths Report (1) · Anne Pember · Identical hazard · confidence 0.90 (high)
- 17 Feb 2025 · Diana Fairweather-Purkis · Paul Appleton · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Rita Taylor · 25 Jan 2023
“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
Later · Jade Griffiths-Jones · 17 Apr 2024
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
What happened next
Evidence found · stated action 1
“The trust's "turnaround plan" lists measures including recruiting more paramedics, tackling sickness and restructuring management.”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
“The trust said it planned to recruit 82 specialist paramedics, 149 paramedics, 24 emergency medical technicians and 96 emergency care assistants.”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
“The recruitment drive, in addition to reducing staff sickness and its spending on private ambulances, would enable it to provide the equivalent of an extra 25 of its own double-staffed ambulances, available around the clock,”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
No evidence found either way · stated action 2
“In 2023, the government published a [plan](https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-urgent-and-emergency-care-services-january-2023/) for recovering urgent and emergency care services, which built on two headline targets: reducing average category two ambulance response times to 30 minutes, and improving A&E waiting times.”
Delivery plan for recovering urgent and emergency care services · thenhsalliance.org/…/delivery-plan-for-recovering-urgent-and-em…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Trump Administration announced $7.2 million in Rural Health Transformation Program (RHTP) funding to modernize emergency medical services (EMS) for South Dakota. This investment will provide first responders with modern telemedicine tools, expanded training, and faster access to patient data, helping them respond to emergencies and better connect rural patients with care across South Dakota.”
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS · cms.gov/…/trump-administration-announces-7-2-million-expand-amb…
“This article considers how to reliably provide emergency medical services (EMS). EMS responses are critical functions of local governments, yet, in rural areas, many are staffed by licensed volunteers. As requests for emergency health services increase and the workforce decreases, transitioning to a paid workforce is critical to maintaining response capacity. This article discusses the need and”
How Should Rural EMS Funding Streams Be Improved? | Journal of Ethics | American Medical Association · journalofethics.ama-assn.org/…/2025-07
“February 11, 2025 By[[name redacted] R. [name redacted], MS, RN, NREMT-P](https://www.jems.com/author/daniel-r-gerard-ms-rn/) 15 min read ##”
Optimizing EMS and Reducing Ambulance Patient Offload Time: Part 1 · jems.com/…/optimizing-ems-and-reducing-ambulance-patient-offloa…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
“Independent Investigation of the National Health Service in England The Rt Hon. Professor the Lord Darzi of Denham OM KBE FRS FMedSci HonFREng September 2024 © Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit www.nationalarchives.gov.uk/ doc/open-government-licence/version/3 Where we”
Independent Investigation of the National Health Service in ... · assets.publishing.service.gov.uk/…/lord-darzi-independent-inves…
“Independent investigation of NHS performance: terms of reference Published 11 July 2024 ## Applies to England ## Contents”
Independent investigation of NHS performance: terms ... · gov.uk/…/independent-investigation-of-nhs-performance-terms-of-…
No evidence found does not mean the action did not happen.