Ambulances referred by NHS 111 service deliberately delayed under secret trust policy, inquiry finds

Ambulances dispatched after people called the NHS 111 helpline were deliberately delayed under a secret policy authorised by a senior health service executive, a leaked report seen by The Daily Telegraph reveals.

Up to 20,000 patients were subject to deliberate delays under the covert operation, which forced high-risk cases in the South East to automatically wait up to twice as long if their call was referred from the helpline.

An inquiry into the scandal, which was exposed by this newspaper in October, has concluded that the decision to embark on the plan was taken by the chief executive of South East Coast Ambulance trust.

The draft report says Paul Sutton ordered the changes despite direct pleas to him from senior managers raising concerns about the dangers of the scheme.

The “forensic review” ordered by regulators, due to be published shortly, is one of three separate probes into the scandal.

It details how the secret policy came to be introduced, without the knowledge of the trust’s board, without any risk assessment and in clear breach of NHS rules.

A separate inquiry, which will report later this year, is examining the extent of harm caused by the protocols to the thousands of patients affected.

At least 11 deaths have been linked to the rogue protocols.

They include that of a 60-year-old Sussex man who was forced to wait 35 minutes for an ambulance, despite suffering clear signs of a cardiac arrest while on the phone to 111 call handlers.

A third investigation is examining how the governance of the trust was so lax that policies were in operation without the authority of the trust’s board.

Under NHS rules, calls designated as “life-threatening” are supposed to receive an ambulance response within eight minutes - regardless of whether the caller dials 999 or the non-emergency 111 line.

But the ambulance trust, which covers Sussex, Kent, Surrey and North East Hampshire, unilaterally invented its own system to "stop the clock" and routinely downgrade 111 calls.

As a result, up to 20,000 callers - including cases classed as “life-threatening” – were told that an ambulance was on its way, when in fact the call had been placed in an automatic queue, adding up to 10 minutes to their wait.

The covert nature of the operation meant 111 call handers promising to send an immediate ambulance had no idea their instructions had been over-ruled.

The orders to "stop the clock" also allowed the trust to falsely claim it was hitting key NHS performance targets, improving performance by up to 5 per cent.

The report ordered by NHS regulator Monitor, is deeply critical of the decisions taken by Mr Sutton, who has led the trust since 2006, on a salary of £160,000, after receiving a £30,000 pay rise over two years.

It also criticises senior managers for claiming plans had been authorised by local commissioners, who in fact had not been alerted.

And it accuses senior executives of attempting to cover up their failings when the truth began to emerge.

The damning report concludes: “Our overall conclusion from this review is that there were a number of fundamental failings in governance at the trust which resulted in the implementation of a high risk and sensitive project without adequate clinical assessment or appraisal by the board, commissioners or the 111 service.

"The CEO made the ultimate decision to proceed with the pilot and played a critical leadership role throughout.”

Over the course of 2014, executives at the trust had openly discussed plans to allow slower responses to the least urgent 111 calls - classed as "green" - in order to prioritise the most pressing "red" cases.

A pilot scheme for "green" calls was agreed with local commissioners.

But Mr Sutton used a private conference call to alter the plan - so that thousands of life-threatening "red" calls, which are supposed to receive an 8 minute response, were also given an automatic delay.

The critical decision on December 4 2014, affecting calls from 20 December 2014 until 24 Feb 2015, was taken despite serious concerns lodged by other managers.

The inquiry report says several senior staff tried to object, but felt they had no choice but to follow the chief executive's orders.

The orders from Mr Sutton meant an automatic delay for all calls classed as "Red 2" which came to the ambulance service via 111.

• How NHS 111 helpline refuses to send out ambulances

These calls are life-threatening, such as stroke, with a target to respond to 75 per cent of cases in 8 minutes.

Several managers raised concerns about risks to safety, the report says.

Others questioned the decision to "stop the clock" on the calls - which meant the delay was not officially registered, improving the trust's performance on the 8 minute target, in clear breach of NHS national rules.

The report states: "Concerns were raised by a number of senior colleagues to the CEO in early December 2014 regarding the inclusion of Red 2 calls in the Pilot.

"These concerns were not adequately addressed and the CEO instructed that the pilot should go ahead."

Senior managers told investigators from Deloittes that they raised their worries, despite fearing that doing so might cost them their jobs, in a forthcoming restructure.

Records note that the trust's then medical director, Dr Jane Pateman - who left within months of the scheme beginning - “wasn’t comfortable” with the addition of life-threatening calls to the pilot.

The report states: "We were informed that it was a direct instruction from the CEO to include the red calls in the pilot."

It quotes a series of senior staff describing pressure to comply with the orders.

One said: "In the end, we all felt that it had to be done, because the CEO directed it – he was the only executive on the call. From that point we just made it as safe as we could.”

Another manager told the inquiry: “When the CEO chairs the group that puts the pilot in place you don’t question it," while another concluded: "It is career limiting not to go forward with this as it was ‘coming from the top'".

One member of staff described "an ‘improper level of pressure was applied to certain individuals" to ensure the scheme went ahead.

The report concludes that the failure to disclose the plan to the trust's board "represents a serious breach of executive accountability".

Local commissioning groups - which are supposed to supervise safety - only learned about the scheme when contacted by a whistleblower alerting them to it, two months after it began.

The anonymous insider warned of a number of serious incidents, including several deaths, among those delayed under the protocols.

Once commissioning groups ordered the scheme stopped, trust managers appeared more concerned about the impact of this on performance than on the reasons why it had been stopped, the report suggests.

Deaths linked to the rogue protocols

A separate inquiry is examining the extent of harm caused to patients by the decision to delay ambulances for thousands of life-threatening calls.

At least 11 deaths have been linked to the rogue protocols, the draft “forensic review” says.

In one case - known to be that of a 60-year-old man from Sussex - a call was put in the queue even though the patient was suffering clear signs of a cardiac arrest,.

A previous NHS report describes “missed opportunities” to improve the outcome for the man from Horsham, who died after waiting 35 minutes for an ambulance.

Other patients who suffered delays under the protocols included an 8-day-old baby, where the clinical outcome was not documented.

The covert operation was only stopped in February, when an NHS whistleblower alerted local commissioners to a string of serious incidents among patients subjected to the policy, including a number of deaths.

Insiders have raised concerns that as many as 25 deaths could be linked with the protocols.

In November, a report by NHS England said the trust’s own attempts to review the impact of its policy were inadequate, and relied on unreliable methods to assess harm.

Regulators ordered a fresh review, to attempt to determine the impact of the delays on thousands of patients, which is due to report later this year.

The catalogue of failings

The report criticises a number of managers involved in setting up the protocols.

It also questions the role of the trust's chairman, Tony Thorne, who said he was unaware of the key decisions, despite normally being heavily involved in the details of trust business.

The trust's director of clinical operations, Prof Andy Newton, is criticised for signing off the scheme. Both he and the trust's then medical director Dr Jane Pateman also come under fire for not ensuring the plan was disclosed to the trust's board.

And Geraint Davies, director of commercial services, who was responsible for gaining approval from local NHS commissioners, is singled out for failing to bring to light plans to include life threatening calls in the scheme.

Unnamed senior managers are also criticised for producing misleading documents after the scheme was exposed, implying that it had the support of senior managers who had opposed it.

But the greatest criticism is reserved for Mr Sutton, who is likely to come under pressure to resign over the scandal.