NHS England follow-up report into an unofficial call-handling project at South East Coast Ambulance Service NHS Foundation

SECAmb’s governance system is made simpler and clear and is not circumvented

Patients and carers should be present, powerful and involved at all levels of the organisation including consultation on any projects that are implemented. Their voices should be seen as an asset in monitoring the safety and quality of care

Transparency within SECAmb should be complete, timely and unequivocal

Leadership within the organisation must promote a culture that supports quality and clinical governance, and this must be implemented at all levels of the organisation

All quality improvement projects are skilfully managed with everyone understanding their responsibilities and accountabilities

Commissioners not providers should decide what they want provided

The CCG should identify within their contract how the Trust can approach any potential change to operating standards

Investigations into serious clinical incidents need to be objective and include families from the outset

Improved oversight and scrutiny from the commissioners with formal reporting structures, more accurately minuted meetings with better attendance and governance adherence

Improved internal organisation within SECAmb, improved communication between the corporate/operational/clinical governance structures must be implemented

Organised engagement with patients and the public for timely stakeholder involvement needs to be formalised and actioned