Margaret Stemp
25 Jun 2018 · Coroner Penelope Schofield · West Sussex
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. insufficient ambulance resources
“there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours”
2. police providing welfare support
“the Police had to be used to provide the necessary welfare support to these ladies”
3. lack of clinical appreciation of deterioration
“the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance”
4. absence of clinical oversight in ambulance stand-down decision
“there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend”
Linked reports
Closely relatedConfidence 0.92 · high
This report
“(1) That there were insufficient resources to deal with the high number of calls on”
Later report
“There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”
Closely relatedConfidence 0.85 · high
This report
“there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours”
Later report
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources”
Responses
2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust.pdf ↗· South East Coast Ambulance Service
Stated action · next three years
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”