The Report of the Independent Review in to alleged failures of patient safety and governance at the North East Ambulance Service (NEAS)

NEAS to meet with families and formally apologise for failings and impact on them.

To undertake a specialist support review of governance in the Trust with specific attention being given to Serious Incident management and compliance processes.

To address concerns that reports were changed inappropriately and consider whether accountability arrangements in the organisation have been followed through and whether further action needs to be taken.

To ensure that training given to all call handlers and health advisors reinforces the need for staff to ask for help where clinical safety of patients is an issue.

The Board should seek assurance of the ongoing coherence and confidence of the Quality and Safety directorate given the painful experiences they have had during this period and the imminent further change of executive leadership of that function.

To develop an oversight committee with family involvement to ensure that all recommendations made in respect of the cases and this independent investigation have been sustainably implemented. It is also suggested that the committee should have a Chair independent of the Trust to oversee these arrangements. (See 10.22)

A Senior Doctor, independent of the Trust, is included in the review of deaths, their referral to HMC, and engages with the families in an appropriate and timely manner. To facilitate this at speed, the organisation should consider adopting the Medical Examiner model into its processes.

The teams should have a clear structure for information flows, clear responsibilities, and the C&C Team acting as the only conduit to HMC.

The function of statutory reporting to HMC via the C&C Team and internal governance processes should be explicitly separate.

NEAS’s latest revised process should be followed, and assurance arrangements put in place by the Nomination and Renumeration Committee to ensure it is.

All situations leading to potential settlement agreement should be scrutinised on behalf of the Nomination and Remuneration Committee, including independent challenge, to ensure best practice is assured.

The Nominations and Remuneration Committee should consider requesting a report providing assurance about any SAs agreed prior to April 2020.

External support for developing, and providing support and challenge, to the Board overall and new directors specifically should be commissioned and a process for rigorously assuring performance put in place.

The revised F2SU arrangements must be implemented as a priority and external review of them, and any recommendations from the national review, commissioned at an appropriate time.

The Culture Development plan should be prioritised and a process to assure delivery put in place by the Board.

We recommend that the Trust needs to engage with the forthcoming national review of broader cultural matters in ambulance trusts arising from the National Guardian’s speaking up review report.8

To support the proposal currently being put forward by the commissioners to improve the commissioning arrangements moving forward. We would also recommend that that the National Framework for the Commissioning of Ambulance Services be updated to better reflect the commissioning complexity and specialist nature of these essential services and improve the governance and oversight arrangements.

To develop a coherent Medium Term Resource plan with ambulance commissioners to secure safe and sustainable services.