Deaths in the NHS: Ambulance Trusts
A matter of life or death
Coroners have been sending reports to organisations to take action to prevent future deaths for over 11 years. However, no one is responsible for understanding who receives these reports, whether they respond, and if action is taken. The Preventable Deaths Tracker is changing this: the only platform that provides real-time statistics.
To highlight what the Preventable Deaths Tracker’s databases can do, I’m launching a new series to share specific analyses on the organisations receiving coroner reports. Today, I’m starting with Ambulance Trusts - the service we rely on in emergencies, often matters of life or death.
217 coroners’ reports
There are 11 Ambulance Trusts in England and Wales. Collectively, coroners sent 217 reports to Ambulance Trusts between July 2013 and 24 November 2024. One-fifth (22%) of reports were sent to the Welsh Ambulance Services, and one-tenth (12%) were sent to the London Ambulance Service.
Every organisation that receives a coroners’ report should respond to all (100%) reports by law. The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published. The London Ambulance Service has the worst response rate, with only one-third (35%) of reports with published responses.
Trends over time
Ambulance Trusts received the most (16%) reports in 2019, with trends dropping during the COVID-19 pandemic.
Do Ambulance Trusts track their reports?
Organisations don’t publish statistics on how many reports they receive from coroners and what actions they take to prevent future deaths. Sharing this information would build a national learning culture where similar organisations could adopt similar actions.
To understand whether Ambulance Trusts were capturing (and hopefully using) this information, I asked them. The majority (54%) of Ambulance Trusts initially refused to share any information, citing that it was already available via the judiciary website. But as I’ve mentioned before, the entire “system” relies on email exchanges, so not all written reports get published. After explaining this, one-third (36%) of Ambulance Trusts continued to refuse to share any information, including:
The remaining Ambulance Trusts shared all or some of their data. When comparing the information shared with the Judiciary website, three Ambulance Trusts underreported (i.e. the Trusts are missing reports), and two Ambulance Trusts reported more reports (i.e. the judiciary website is missing reports). It’s a mess.
The Welsh Ambulance Services University NHS Trust reported that since 2022, they’re using a national database 'Once for Wales' Datix Cymru system to record its inquest management. So, it’s great to hear work is being done to improve data capture, but English Ambulance Trusts (and the other 2,000+ organisations that receive coroners’ reports) now need to follow.
The Verdict
The lack of any “system” to track and use coroners’ reports is a missed opportunity. Local approaches to improve data capture are a positive start, but a national approach is needed. Until then, the Preventable Deaths Tracker will keep tracking.