Ambulance service `needs extra £3m a year'

Ten factors contributed to the "inexcusable" delay in attending Nasima Begum, the draft report says. She died three hours after reaching hospital, from acute pulmonary oedema, a rare complication of her kidney condition which requires rapid treatm ent toprevent death.

According to the drafts, Sunday 19 June was exceptionally busy, with 120 instead of a typical 60 calls between 10.41pm - when the family first dialled 999 - and 11.28pm when an ambulance finally arrived.

The standard of call-taking was poor. No single person was responsible for linking the five calls Nasima's family made. There was no procedure for prioritising calls, nor the information available safely to do so, and no ambulances were available close to her.

Eighteen should have been on duty in the vicinity of her home up to 11pm, but only 12 were, "mainly because of holiday and sickness absence". After 11pm, 13 vehicles should have been available, but only seven were staffed. Two were given the same radio identification, resulting in one not being used for the first 54 minutes of the shift.

The shift had changed 19 minutes after the first call, and control staff, facing intense pressure with diminished resources, had permitted two vehicles crewed by staff from separate stations to return early to allow the more distant crew members to get back to their home base.

The situation demands urgent action, the inquiry says, making 52 recommendations.

The report says London Ambulance has five radio channels when ideally it needs eight, but that the NHS Executive has told the service that no further channels can be made available.

On top of the extra £15m a year the service has received recently, almost another £3m a year needs to be spent, much of it on extra control staff because ambulance allocators have to carry in their heads the location and operational status of up to 70 ambulances. Allocators in other services handle only 25 to 30 ambulances. And another £14m is needed in capital and one-off costs.

The management chain of command is too long. LAS directors have to seek agreement for capital and strategy decisions from the advisory committee, which in turn reports to the South Thames region which manages the service. Decisions can be further delayedwhen North Thames and the NHS Executive have to sanction them.

With the service's directors not responsible for their own destiny on many important matters, there is "a lack of decisiveness", the drafts say.

The inquiry found some ambulance stations had too many staff and others too few, while the almost universal shift change of both crews and controllers at 11pm, 7am and 3pm was "disruptive and therefore dangerous". It should be abandoned for a more phasedchange-over.

Because a call in the last hour of a shift makes it likely that crews will finish late, they are tempted to use the last hour to refuel or carry out other duties which make them unavailable.

The service suffers from a conflicting culture, some staff seeing themselves as part of a heirarchical emergency service like the fire or police, others as part of an informal caring service. Crews and control do not understand eachother's problems, generating both a "blame culture" and, "dangerously", a lack of respect among crews for instructions of control staff.

The vast majority of crews are conscientious. But "there appear to be a minority who take advantage of the system and any perceived weakness in management". Conscientious crews want such behaviour dealt with, but "discipline has slipped and some staff may have lost sight of the fact that the LAS exists above all to provide an emergency service, the prime objective of which is to save lives". Absence levels run at 9 per cent, are particularly high at night and weekends, and often too few staff are on duty at the busy 11pm-2am period. Action to reduce absences must be taken.

The drafts say the service should move to NHS Trust status, with extra resources provided to allow that, and planned improvements in technology should be implemented on time.Management should be restructured, staff transferred from overmanned to undermanned stations, and, pending a properly computerised system, a medical referee should be available to prioritise calls.