Lucas Pollard

“Critical Care Team was not dispatched immediately given the serious nature of the call and the likely lack of clinical information for some considerable time ie waiting for the land ambulance, known to be more than 20 minutes away, to arrive and assess”

“End Of Shift Policy was applied without evidence of an ongoing reassessment of the situation and the RRV, positioned only 3 minutes from the incident, was consequently not deployed”

“clear evidence from the 999 call both from the caller and the obvious deterioration of [the deceased] from sounds in the background but that did not prompt a review of the management of the incident by EEAST”

“Application of the policy as it was, in future situations, may represent a threat to a patient's life”