Unnecessary 999 calls from prisons lead to a ‘significant’ loss in ambulance crew time

Our investigation examined the emergency response to patients in prison. We were told the volume of 999 calls being made is reaching levels which hinder both the prison and emergency services. This also has a knock on effect to people in the community.

Impact of diverts

Based on figures from one ambulance trust (there are 10 trusts in England), we carried out our own analysis to understand the impact of the diverts.

Crews described diverts as short as 2 minutes but as long as 10 minutes. The investigation used a 5 minute average and a minimum 2 minute divert time for representation. The 5 minute divert equates to approximately 1,250 hours (7 weeks) of ambulance crew time per year. They also calculated it would equate to over 100 12 hour ambulance crew shifts. It is important to note that the amount of time spent on calls that are then cancelled are not recorded by any national organisations.

Prisons employ a system where the emergency is called by prison officers. The control room then phones 999 and they wait for the emergency response nurse at the prison to assess the patient and determine whether the 999 call should be stood down or if the ambulance is needed. Prison staff told HSSIB that most 999 calls were eventually cancelled by the nurse.

The report includes data from the Association of Ambulance Chief Executives (AACE) on calls made across England, including prisons. It shows that in prisons approximately 3 in 4 calls (71%) did not need an ambulance compared to 1 in 8 (12%) nationally.

The report states the figures reflect the frustrations of ambulance crews and emergency centre call handlers and dispatchers. Crews told the investigation the diverts were causing delays to treatment for people who needed it. One ambulance crew said “we waste vital time driving to a prison for a call which then gets cancelled and we’ve just added that time on to the response to someone who needs us”.

Contributing factors

Our investigation identified several factors contributing to a large number of 999 calls being made for a non-emergency. This includes:

• A low threshold of what serious injury was - staff told HSSIB they were worried about what the outcome could be for the patient. They were afraid of having to attend the HM Coroner’s court and being blamed for making a wrong decision.
• Prison policies encouraging a low-risk approach which left staff no room to make decisions. Prison policy states ‘it is better to act with caution and request an ambulance that can be cancelled if it is later assessed as not required’.
• High prison staff turnover, which resulted in a lack of experience among staff who were first on the scene of medical incidents.
• No embedded recurring training to support prison staff to recognise medical emergencies requiring a 999 response.

The investigation highlighted that the emergency response card (which details the nature of code blue/code red categories) is not designed to best support prison staff in identifying a medical emergency. It does not ensure sufficient information is passed to ambulance call handlers. The card lists conditions fitting into the two codes but there is no detail about what meets the criteria. For example, ‘severe loss of blood’ is the first category for code red but does not describe what ‘severe loss of blood’ means.

Communication between organisations

We emphasise that a ‘significant area’ for improvement is communication between organisations.

A key finding in the investigation is that information is passed from the scene via multiple handovers before it is received by the 999 call handlers. Prison staff on the scene of a medical incident are not talking directly to 999 call handlers. The prison control room who are talking to the 999 call handlers rarely get ‘situational information’. They are just told it is ‘a code red or code blue.’ This means sometimes the information received by the emergency services does not always reflect the medical emergency.

The investigation heard examples including:

• A patient being described as ‘unresponsive’, which in clinical terms means the patient is unconscious, prompting the dispatch of an air ambulance and multiple ambulance crews. However, on arrival ‘unresponsive’ was found to mean the patient was refusing to answer questions.
• An ambulance crew had been advised they were attending a patient aged 90 who had twisted his ankle. Upon arrival the crew found the patient was a man aged 30 with multiple stab wounds.

Ambulance crews described how the lack of accurate and appropriate information directly affected their ability to prepare for callouts to prisons. Overall, they expressed frustration that the same problems were being encountered repeatedly. Prison officers told the investigation there was no way of raising concerns or issues that arise during emergencies. Prison management said they were aware of incidents and some problems that had occurred, but they had no communication with ambulance trusts, other than the attending crew, to address these.