Clinical errors were to blame for more than half of all serious incidents involving West Midlands Ambulance Service that resulted in patient harm.
Inappropriate patient discharges, cardiac arrests, and choking management were found to be common themes in a trust audit.
It also stated that the choice to shut down all community ambulance stations was made without first conducting a thorough risk analysis of the implications for public safety.
As a result of the subsequent actions, serious incidents have decreased.
The closure of ambulance stations has been independently validated, according to the West Midlands Ambulance Service (WMAS).
WMAS conducted an audit after the number of serious incidents rose from 138 in 2021–2022 to 327 in 2022–2023 and discovered that 53% of them were the result of mistakes with their treatment.
Serious clinical incidents are those where someone receives significant harm while receiving care.
5,000 serious patient incidents reportedly caused the trust to delay investigating them.
In January 2022, Jamie Rees-Issett, age 18, suffered a cardiac arrest in Rugby and passed away after waiting more than 17 minutes for an ambulance.
For an investigation by the ambulance service, according to Mrs. Rees-Issett, she had to fight.
"This does not surprise me at all," she said. "I know how long we waited and how hard we tried to get any form of investigation.".
WMAS claimed that it lacked an ambulance that could have arrived sooner in this case because crews were stranded outside hospitals.
It claimed that a significant portion of its serious incidents were brought on by ambulances being held up outside hospitals while paramedics waited to transfer patients, which had an adverse effect on other facets of its service.
"We instituted more checks after realizing what was going on. We have seen a decrease in the number of serious incidents as a result," it said.
Concerns were raised about staff members adhering to the correct procedures.
According to Murray MacGregor, director of communications, "The trust looked at what was happening and took necessary action to remedy the situation.".
The West Midlands Ambulance Service has announced that it is hiring 10 additional employees to investigate patient safety incidents.
The trust claimed a new system had been put in place to address the backlog of 5,000 cases.
As a result, we have discovered several incidents that weren't properly investigated. All of those cases have now been looked at, Mr. MacGregor said.
"Three of the incidents led to the identification of serious ones, which are now the subject of investigations. ".
The Rugby community ambulance station and ambulance stations throughout the region were decided to close in October 2021, months before Jamie Rees passed away.
The choice was made without conducting a thorough risk assessment, according to the minutes of a quality assurance meeting held in January, just days after Jamie's passing.
According to the minutes, Mark Docherty, the nursing director at the time, told the quality governance committee that "the process was slightly cart before the horse as the closures had occurred before the quality impact assurance had been completed.". " .
The trust lacked the funds to invest in the Community Ambulance Service, Mr. Docherty claimed, though he did not advocate its elimination.
"We have let ourselves down badly as an organization," said Unite union representative Steve Thompson, calling the procedure "quite deplorable.". ".
To oppose the closure of their ambulance station, several council members were chosen for the Evesham Town Council.
They started a legal challenge of the judgment, but Judge Ian Dove rejected their request for leave to appeal on the grounds that the modifications had no appreciable effect on the quality of the service they had received.
When councilwoman Julie Haynes learned of Mr. Docherty's remarks regarding the quality impact assessment, she was astounded.
"That phrase [quality impact assurance] is something I've never heard of," she remarked. and it truly saddens me because I believe we could have prevailed, saving the town's ambulance service and making the judge more sympathetic to our cause.
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