Ambulance delays outside hospitals are harming 160,000 patients, leaked report warns

Exclusive: As many as 12,000 patients a year could be suffering severe harm as a result of long waits outside A&E

Ambulances queuing outside the Royal London Hospital in January 2021 (EPA)

Tens of thousands of sick patients are being harmed as a result of ambulance delays outside hospitals, a report leaked to The Independent has warned.

The study, carried out for ambulance service chiefs, estimates there could be as many as 160,000 patients experiencing harm every year in England as a result of being stuck in the back of ambulances.

As many as 12,000 patients, or one in 10, could be suffering severe harm, such as a cardiac arrest, loss of a limb or brain damage.

The damning report, by the Association of Ambulance Chief Executives (AACE) included examples of severely ill patients not being treated properly, being forced to go to the toilet in ambulances, and being denied food and drink, as well as antibiotics and fluids.

The findings underline the systemic problems within the health and social care system, which lacks the capacity and staff to meet rising patient demand.

The Independent reported extensively on the summer crisis that hit ambulance services this year, with record levels of 999 calls and delays leaving patients waiting for hours for ambulances to arrive.

Safety incidents reported to NHS England by ambulance trusts have jumped 26 per cent so far in 2021 compared to the whole 12 months of 2019. Deaths as a result of safety incidents in ambulance trusts are up 13 per cent compared to 2019.

Hospitals don’t have enough empty beds and A&E departments are stretched beyond their limits, meaning they have to force ambulances to queue for hours outside.

Patients are supposed to be handed over to A&E staff within 15 minutes of an ambulance arriving, but in September this year 208,000 patients waited longer.

The report said: “We now have a situation where each month there are over 200,000 patients experiencing handover delays, with up to 25,000 of these delays being more than four times longer than the expected standard of 15 minutes. In the 12 months to September more than 185,000 patients experienced a delay in handover at ED (emergency departments) of longer than an hour.

“We know that some patients have sadly died whilst waiting outside ED, or shortly after eventual admission to ED following a wait. Others have died while waiting for an ambulance response in the community.

“Regardless of whether a death may have been an inevitable outcome, this is not the level of care or experience we would wish for anyone in their last moments. Any form or level of harm is not acceptable, and we need to shine a light on the patient experience of these delays.”

It warned that not enough was being done to fix the problem which had been highlighted as far back as 2012 but which had become far worse in recent months.

Expert clinicians were asked by the AACE to review 470 random cases, drawn from all 10 English ambulance trusts, where patients were made to wait longer than an hour, on 4 January this year.

In its conclusions, the AACE report found “unacceptable levels of preventable harm are being caused to patients”.

It added: “If these results from the 4 January 2021, which was not an atypical day, are extrapolated across all handover delays that occur every day, the cases of potential harm could be as high as 160,000 patients affected per year. Of those, approximately 12,000 patients could potentially experience severe harm as a result of delayed handovers.”

The report said the problem was an issue for all parts of the health service, saying: “This report is not a finger-pointing exercise, and no one sector or provider holds the blame in an ever-fluctuating environment. This is, however, a clarion call for NHS England… to work with providers so that handover delays do not occur and do not result in harm and poor patient experience.”

The report said problems were occurring “on a daily basis”, adding for “some hospitals, every day is a ‘bad day’”.

The AACE warned that even low-level harm such as patients being forced to go to the toilet in the ambulance or being denied food and drink was unacceptable and could still impact on their eventual recovery.

Examples of severe harm identified by the experts included:

• One patient who had two epileptic seizures while in the back of the ambulance during a delay of an hour and six minutes
• A patient who waited an hour and 42 minutes and suffered a severe epileptic fit in the ambulance that required medication and the help of a doctor from A&E
• A patient with Covid-19 who had severely low oxygen levels of less than 50 per cent compared to a healthy level of 95 per cent or above. The patient waited over an hour to be seen
• A separate elderly patient with sepsis who urgently needed antibiotics waiting almost an hour and a half
• A Covid patient delayed for an hour and 29 minutes who was dehydrated and experiencing diabetic ketoacidosis due to high blood sugar, but was not given fluids by nurses who couldn’t get an intravenous line into the patient’s veins
• A learning disabilities patient, who was also positive for Covid-19, who was left waiting for four hours and 41 minutes

The AACE report said these examples and others “clearly demonstrate that it is likely that these delays have led to harm”. It added: “Ambulance clinicians are not trained to care for patients for lengthy periods of time; the ambulance environment and available equipment are not designed for extended periods of patient care; and the ambulance and crew are needed to respond to other patients who have called 999.

“There must be an acceptance that this cannot be allowed to continue, and a program of rapid system improvement must be undertaken to change mindsets where necessary and eliminate the root causes.”

The AACE report also includes statements from staff describing their recent experiences of delays and their impact. One told of looking after a patient who they suspected was bleeding internally, and despite raising the alarm with A&E staff, they were told to stay in the ambulance.

They said the patient “continued to deteriorate”, adding that they “started to go mottled across the abdomen – we were really worried the patient was seriously ill now and close to dying. After 20 minutes of waiting, the patient went into cardiac arrest in the ambulance.” The patient was rushed into A&E but did not survive.

In another case a paramedic said they responded to a patient who had been lying in their own urine “for around 24 hours and had around 17 per cent burns. [The] patient was in pain and distress.” They said they tried to alert the hospital in advance of arriving “but was met with the response that it is going to be 'a long wait and you are at the back of nine ambulances’.”

The patient waited three hours and 20 minutes.

There were 7,361 delays longer than 15 minutes on 4 January, with 1,351 lasting more than 60 minutes.

In 400 cases, or 85 per cent, the reviewers said they believed the patient may have experienced some level of harm, with 42 patients, or almost one in 10, experiencing severe harm.

The South East Coast Ambulance Service reported the longest average waits at two hours and 40 minutes, with more than a third of its incidents rated as severe. The West Midlands Ambulance Service had the most delays over an hour, at 290.

The shortest average wait was one hour 43 minutes, reported by the Yorkshire Ambulance Service.

The AACE said the pressure on experienced staff had reduced some to tears, with many forced to work beyond their 12-hour shifts to hand over patients to hospitals.

The AACE said there needed to be better access to care for the public outside of hospitals and it should be available out of hours. It said capacity in social care needed to be increased so hospitals could discharge patients to free up beds.

All delays over 60 minutes should be deemed unacceptable and investigated as serious incidents, it said, and urged the Care Quality Commission to include handover delays in its inspections of local health systems.

An NHS England spokesperson said: “Staff have gone above and beyond over the last year treating hundreds of thousands of seriously ill covid patients in hospital and most recent data shows record levels of A&E attendances and the highest ever number of 999 calls and life-threatening ambulance call outs in a single month. “NHS services are working collaboratively – including with AACE’s members – in line with actions set out for systems to prevent ambulance handover delays with immediate effect, so the public should continue to come forward through the appropriate route so staff can help you with the best option for your care.”

A Department of Health and Social Care spokesperson said: “We are committed to supporting ambulance crews who work tirelessly responding to emergencies every day.

“NHS England has given ambulance trusts an extra £55 million to boost staff numbers for winter, helping them to bolster capacity in control rooms and on the frontline. “We are supporting the NHS to meet the unprecedented pressures it is facing, with record investment this year including an extra £5.4 billion over the next six months to support its response to COVID-19 and £36 billion for health and care over the next three years.”

The AACE has been approached for comment.