Investigation finds trust has improved after tragic death

Tuesday, 23 September, 2008

Great Western Ambulance Service NHS Trust has made improvements to services following a tragic death, according to the Healthcare Commission.
The Commission's investigation follows concerns about an incident in May 2007, which ended in the death of a woman who was involved in a road traffic accident. The ambulance took 42 minutes to attend the scene at Cirencester in Gloucestershire - 34 minutes over the national target.

In its findings, the Commission says the trust has responded to concerns and made improvements to its service. It says changes such as the introduction of a new ambulance dispatch system, a centralised control room system and a review of its vehicle fleet have contributed to reducing the risk of this incident recurring. The review identified factors impeding a rapid response to emergency calls. These included systems for handling emergency calls, systems for monitoring the location of ambulances, prioritisation of incidents, upkeep of vehicles, staff sickness levels and delays in patient handover times at hospitals.

The Commission highlights that since the incident, the trust has improved its dispatch systems by:

* Merging three call handling systems into one central system based in Bristol
* Implementing a computer-aided dispatch (CAD) system
* The introduction of 'Drive Zones' giving vehicles have an identified geographical patch
* Conducting a review of its air support
* The introduction of a new automated dispatch system.

Nigel Ellis, the Commission's Head of Investigations, said, "The incident that triggered this intervention is a real tragedy. It follows that the trust should continue to do everything possible to ensure it does not happen again.
"We are satisfied that lessons have been learned and the trust is addressing the main concerns by making changes to its systems to reduce the risk of an incident like this being repeated. The new computer-aided dispatch system, staff sickness procedure and overhaul of the vehicle fleet have all contributed to the improvement of the service.

Dr Ossie Rawstorne, Clinical Director, Great Western Ambulance Service responded to the Healthcare Commission report and said, "We accept all five of the Commission's recommendations and will have implemented four of them completely by the end of September. We now have a robust system in place to document serious incidents and complaints and to learn from these. We now also respond more sensitively and appropriately to complaints and comments on our services.
He added, "We have formalised briefing for control room staff and hold weekly operational meetings for staff at all levels. By the end of September our new control room structure will be in place and supported by a formal mechanism to communicate changes in procedures and policy to staff.

"Finally, we have made significant progress on the remaining recommendation made by the Commission. We are working hard to make sure all staff have an annual appraisal with personal development plans and receive all appropriate training."

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