East Midlands Ambulance Service
AI-generated response summary
East Midlands Ambulance Service plans to increase frontline capacity by introducing 20 additional double-crewed ambulances and 191 frontline staff by December 2026, with further increases by April 2028, to improve response times for high-risk presentations. They will also review national escalation outcomes and implement local actions through their patient safety arrangements.
View full response
Dear Ms Pember Re: Report to Prevent Future Deaths in the case of Mr Samuel HAND deceased I am writing to you in response to the concerns that you highlighted to the East Midlands Ambulance Service NHS Trust (EMAS) following the inquest hearing into the sad death of Mr Samuel Hand, that concluded on 12 August 2026 and subsequent issue of the Regulation 28 report. I understand that you will share this response with Mr Hand’s family, and I would first like to express my sincere condolences to them. The Trust acknowledges the concerns you have raised, and I would like to provide the following clarifications and commitments. The concerns set out in your report have been reviewed and discussed by the Trust’s Incident Review Group. The Group meets twice weekly to consider matters arising from complaints and concerns, incident reports, inquests and Regulation 28 reports. This process supports the identification of learning and ensures that appropriate action is taken to address any systemic or procedural shortcomings.
78736638v1
[Page 2] Matters of Concern raised on 12 August 2026 At 04:36, Mr Hand called 999 and reported that he had taken tablets amounting to a total dose of mg, together with an unknown quantity of mg tablets. He also clearly expressed suicidal ideation. Based on the information available, the call was initially triaged as a Category 3 response. Mr Hand’s case was subsequently upgraded to Category 2 at 07:17 the following morning. A double-crewed ambulance was allocated at 07:47 and arrived at his address at 08:01, 357 minutes after the initial 999 call. NHS Pathways is a nationally governed, symptom-based triage system designed to identify immediately life-threatening features, including reduced consciousness, breathing difficulty, seizures, shock and certain recognised high- risk substances. It is not a toxicology calculator and does not assess the clinical significance of every reported dose for every medicine. In the absence of immediately life-threatening symptoms, Category 3 is the lowest ambulance response category available through the pathway for an overdose. In your report, you raised a concern that, when determining the appropriate response category, NHS Pathways did not take account of the quantity of medication reported as ingested and appeared to focus solely on the type of medication involved. Although these measures do not alter the national triage algorithm, the Trust is increasing frontline capacity to support more timely emergency care, including for patients reporting an overdose or other high-risk presentations. Through its Right Sizing Programme and Category 2 Improvement Fund plan, the Trust will introduce 20 additional double-crewed ambulances and 191 frontline staff by 31 December 2026, providing around 2,100 additional ambulance hours each week. An equivalent further increase is planned by April
2028. Delivery is monitored fortnightly and recruitment is progressing. These measures are intended to improve ambulance availability and support achievement of a mean Category 2 response time of 30 minutes or less. The Trust remains committed to learning from this case and to strengthening the recognition, recording and escalation of risk for patients reporting an overdose. We will ensure that the outcome of the national escalation is reviewed through the Trust’s patient safety and clinical governance arrangements, and that any required local actions are implemented and monitored. I hope this response provides assurance regarding the action the Trust is taking. If I can be of any further assistance, please do not hesitate to contact me.
78736638v1
[Page 3]
78736638v1
[Page 2] Matters of Concern raised on 12 August 2026 At 04:36, Mr Hand called 999 and reported that he had taken tablets amounting to a total dose of mg, together with an unknown quantity of mg tablets. He also clearly expressed suicidal ideation. Based on the information available, the call was initially triaged as a Category 3 response. Mr Hand’s case was subsequently upgraded to Category 2 at 07:17 the following morning. A double-crewed ambulance was allocated at 07:47 and arrived at his address at 08:01, 357 minutes after the initial 999 call. NHS Pathways is a nationally governed, symptom-based triage system designed to identify immediately life-threatening features, including reduced consciousness, breathing difficulty, seizures, shock and certain recognised high- risk substances. It is not a toxicology calculator and does not assess the clinical significance of every reported dose for every medicine. In the absence of immediately life-threatening symptoms, Category 3 is the lowest ambulance response category available through the pathway for an overdose. In your report, you raised a concern that, when determining the appropriate response category, NHS Pathways did not take account of the quantity of medication reported as ingested and appeared to focus solely on the type of medication involved. Although these measures do not alter the national triage algorithm, the Trust is increasing frontline capacity to support more timely emergency care, including for patients reporting an overdose or other high-risk presentations. Through its Right Sizing Programme and Category 2 Improvement Fund plan, the Trust will introduce 20 additional double-crewed ambulances and 191 frontline staff by 31 December 2026, providing around 2,100 additional ambulance hours each week. An equivalent further increase is planned by April
2028. Delivery is monitored fortnightly and recruitment is progressing. These measures are intended to improve ambulance availability and support achievement of a mean Category 2 response time of 30 minutes or less. The Trust remains committed to learning from this case and to strengthening the recognition, recording and escalation of risk for patients reporting an overdose. We will ensure that the outcome of the national escalation is reviewed through the Trust’s patient safety and clinical governance arrangements, and that any required local actions are implemented and monitored. I hope this response provides assurance regarding the action the Trust is taking. If I can be of any further assistance, please do not hesitate to contact me.
78736638v1
[Page 3]