NHS England investigation into an unofficial call-handling project at South East Coast Ambulance Service NHS Foundation Trust

There is independent assurance for achievement of any action plans developed in response to this investigation in addition to the CCG.

SECAmb’s governance system is made simple and clear and that it is not circumvented.

Patients and their 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 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 CCGs should identify within their contract how the Trust can negotiate change to operating standards.

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

There must be 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 corporate/operational/clinical governance structure must be implemented.

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