South Central Ambulance Service NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

We assessed all 8 quality statements from this key question.

At the last inspection we rated this key question inadequate.

At this inspection the rating has improved to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed.

We found 2 breaches of regulations in the key question, in relation to safe care and treatment, there was a lack of an appropriate and effective system to ensure oversight of controlled drugs, and in relation to staffing, there was a lack of clinical oversight to ensure staff were supported and had effective development, to consistently deliver safe care and treatment to patients.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had systems and processes in place to investigate and report safety events. However, there was a lack of oversight to ensure learning from safety events was implemented and good practice embedded.

The service had processes to collect data from various sources, including performance and outcome data, and feedback from patients and staff. There were policies, procedures and meetings to interrogate and investigate data. The results were used to actively learn from findings and drive continuous improvement, and implement changes in practices to improve safety, care and outcomes for patients. For example, the thematic analysis on ambulance delays and the impact on patient outcomes, and changes needed to reduce delays.

Staff were encouraged to raise concerns and report incidents and near misses in line with trust policies. Staff told us they knew how to raise concerns and could give examples when they had. However, staff still said finding the time to report incidents whilst operating at high demand was challenging and gave us examples when they had not reported incidents. In addition, if they reported incidents they did not always get feedback.

Between April 2024 to March 2025 there had been 5365 incidents reported. 87% of incidents were rated as no harm, 11% rated as low harm (minimal harm – patient required extra observation or minor treatment), 0.7% rated as moderate harm (short term harm - patient required further treatment, or procedure), 0.6% rated as severe harm (permanent or long-term harm) and 0.3% deaths. The incidents were categorised to see if there were any themes or trends, the top 4 themes were, response time delays (40%), clinical care delivery issues (35%), behaviour and security (34%), medication-related incidents (10%) and non-attendance (5-7%). Incidents were reviewed and investigated according to the trust’s policy and processes and action taken if required.

The trust had implemented the April 2024 NHS England’s Patient Safety Incident Response Framework (PSIRF), which had changed how incidents were investigated and concentrated on the learning and improvement of patient safety.In the first year, the trust had successfully focused on the corporate oversight of the management of PSIRP to make sure systems were in place to effectively follow the framework. Further work was planned to have a devolved model, where the operational team would lead their incident responses and take on PSIRF responsibilities.

We found there was mixed understanding of PSIRF with operational staff, with some staff saying there had been no changes but others being able to explain the new process of how incidents were reviewed, categorised and investigated by either the patient safety team or by the local team. Senior operational staff felt more support and training was required as PSIRF was currently not embedded in the service. The trust had added 2 modules to the mandatory training of staff, patient safety level 1 and patient safety level 2, although this training was not PSIRF specific it gave staff an understanding of patient safety and aligned with PSIRF principles. As of March 2025, 97% of staff had completed level 1 training and 93% had completed level 2. However, not all operational staff involved in PSIRF investigations had received specific training on PSIRF.

Learning and improvement actions from incidents was shared with staff in various ways via clinical memos, SCAS learning snapshots, team meetings and the patient safety newsletter. It was acknowledged by managers that there was a reliance on staff to make sure these communications were read and changes in practice acted upon. There was no system in place to check communications had been read, understood or implemented by staff.

The service used complaint data to improve services. Between April 2024 and March 2025, there was a total of 137 formal complaints received. The main themes being clinical care (45%), staff attitude (26%) and care/handling towards patients and their property. In the same timeframe the patient experience team received 1291 patient experience cases for the emergency and urgent care service, the main themes being, delays in ambulance response (17%), inappropriate care pathway (14%), and behaviours of staff (13%).

The trust had processes and practices to ensure all complaints were reviewed, reported and responded to according to the trust’s complaint policy. If a complaint was seen to be a patient safety concern, the complaint would be investigated via the patient safety team. Complaints not seen as a patient safety concern would be investigated by the patient experience team or at a local level by the operational teams.

Learning and improvement actions from complaints was dependent on the route it had been investigated and the resulting actions identified. For complaints investigated by the patient safety or patient experience teams, learnings would be shared in a similar way to learning from incidents and via a ‘hot news’ information sheet. Complaints investigated at a local level were usually dealt with by the team leader, and the emphasis was on the team leader to share any learnings with the rest of the service, if appropriate. Most team leaders felt they had the appropriate training to support conversations with their teams regarding complaints.

The trust had recently undertaken a quality improvement project on the way compliments were recorded and disseminated. Compliments were now recorded and reviewed in the same manner as complaints. This was seen as a way to highlight good care, share good practice, and to acknowledge when staff had performed well. Between April 2024 and March 2025, the service had received 1168 formal compliments.

Staff understood duty of candour and said they were open and transparent and gave patients and families a full explanation if and when things went wrong. We reviewed patient safety information and minutes from the safety review panel and patient experience meetings which showed duty of candour was now discussed and completed appropriately when required.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Ambulance crews explained they were briefed by call handlers before arriving to a patient and given information such as the age, patient’s symptoms and the urgency of the situation to help them prepare and be able to provide efficient and effective care upon arrival.

On arrival, ambulance crews used established guidelines and their own clinical expertise to evaluate the patient and determine the necessary course of action, to ensure that each patient received the most suitable and timely care, leading to the best possible health outcomes. This process involved a structured assessment, clinical judgment and decision-making, and helped prioritise patients and direct them to the most appropriate level of care.

Staff had access to support and advice from other healthcare professionals to help manage patients safely. This included the South Central Ambulance Service (SCAS) urgent care or clinical support desks staffed by clinical staff, or phoning a patient’s GP surgery. Crews said this mostly worked well but out of hours it could sometimes be hard to get immediate support.

Ambulance crews used clinical pathways for patients’ onward care and treatment. Clinical pathways were available for ambulance crews on their handheld mobile device. SCAS had a dedicated team to help develop effective pathways with the local healthcare community to help alleviate pressures at hospital emergency departments and to make sure patients were receiving timely access to the appropriate care. These included same day emergency care (SDEC) units in hospitals and single point of access (SPOA) in the community, who could provide rapid coordination of community services to meet a person’s urgent need. However, staff told us these schemes were in their infancy and needed further development between SCAS and other healthcare organisations. For example, 2% of patients had been transferred to an SDEC between May 2024 to Apr 2025. Staff still tended to use see and treat, where ambulance crew could assess a patient’s condition at the scene and, if appropriate, provide treatment and/or advice without the need to transfer to hospital, or transfer patients to emergency departments where their care would be continued.

Ambulance crews continuously monitored patients whilst they were being transferred to hospital, including monitoring vital signs to ensure patient stability and guide treatment decisions. Ambulance crews recorded patient data on electronic devices ensuring secure and confidential records. This data included basic patient information (name, address, date of birth), medical history, vital signs, symptoms, and treatment details. The system allowed for real-time access to patient records and integration with other healthcare systems, streamlining information sharing and improving decision-making during emergencies.

Ambulance crews had systems in place to pre-alert the receiving emergency department about the patient’s arrival. This included sharing of systems that tracked the ambulances and their estimated arrival time, or crews could call ahead to inform them about a critically ill or rapidly deteriorating patient who was en route. This allowed the emergency department to prepare for the patient's arrival by freeing up resources, getting specialist staff ready, and potentially initiating time-critical treatment.

On arrival to hospital, ambulance crews handed over patients and their care to hospital staff in a thorough and structured process that involved verbal feedback and an electronic report. This process ensured a smooth transition of care, accurate information transfer, and patient safety. We observed handovers and all were carried out to a high standard, and feedback from the receiving hospitals were positive.

National guideline and best practice say that ambulance handovers should be within 15 minutes of arrival of the ambulance to the receiving hospital. However, it is recognised that handover delays across the country are significant due to system pressures across the health and social care landscape. SCAS were performing well when benchmarked against other ambulance trusts. From Oct 2024 until March 2025, SCAS, when handover data was averaged across the patch showed 43% of patients had a handover within 15 minutes, 89% of patients within 30minutes and 98% within 1hour. There was some variation across the patch due to system pressures in that area. Until handover occurred ambulance crews were responsible for monitoring the patient. SCAS had worked hard with healthcare partners to reduce handover times, as delayed handovers had been shown to impact patient safety by delaying immediate care and treatment and reducing the availability of ambulances out in the community.

The ambulance trust had brought in the release to respond initiative. This was an agreed process with the receiving hospitals which saw the safe withdrawal of the ambulance crew within 45 minutes, releasing them to respond to patients in the community, thus creating continued patient safety across all areas of healthcare. Since the initiative went live in December 2024, there had been a significant improvement in response times to patients in the community, and lost crew hours waiting to hand patients over at emergency departments. For example, in November 2024, the average time for SCAS to reach a category 2 call was 37 minutes, in March 2025, this had reduced to 22 minutes. In addition, crew hours lost to waiting at the hospital had reduced from 5525hrs in November 2024 to 2638hrs in March 2025.

The service employed specialist paramedic practitioners who were able to self-allocate jobs to themselves and monitored the list of outstanding category 3 (urgent) calls. They could call patients back, refer to different healthcare agencies or upgrade or downgrade the urgency category of patients. Specialist paramedic practitioners were able to use their clinical judgement to make clinical decisions rather than following care pathways.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Improvements had been made to all aspects of safeguarding. The trust had created a culture of awareness, prevention and effective response to potential harm by improving training, having clear reporting procedures, and robust partnership working with other agencies.

Safeguarding was part of the staff induction and mandatory training. Staff working in the emergency and urgent care service had received the appropriate level of adult and children safeguarding training for their role. Training records showed that 96% of staff had completed their safeguarding training for both adults and children, which met the trust’s 90% completion rate target.

The service had well-defined and easily accessible policies and procedures for safeguarding, ensuring staff knew how to identify, report and respond to potential concerns. Staff understood their role and responsibilities in protecting patients from abuse, could give examples of when they had made a safeguarding referral, and explained the process of doing so via their electronic patient record (EPR). There were back up procedures in place in case of technical failures with the EPR.

Frontline staff explained how the trust’s safeguarding team was now more visible and supportive. They had worked with frontline staff to improve the quality of safeguarding referrals and used audits to ensure continued appropriateness and quality of referrals.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

When people called 999, they were assigned an urgency category based on their condition, which determined the type and time of the response from ambulances. These are category 1- calls from people with life- threatening illness or injuries, category 2- emergency calls, category 3- urgent calls and category 4 less urgent calls. These categories helped the appropriate response time and resources needed.

Crews were dispatched to emergencies by the emergency operations centre. On arrival ambulance crews used established guidelines and their own clinical expertise to evaluate the patient and determine the necessary course of action, to ensure that each patient received the most suitable and timely care, leading to the best possible health outcomes

The trust used volunteer community first responders (CFR) to respond to emergencies in their own communities. The CFR was able to relay patient information back to the urgent care desk in the emergency operations centre.

Staff completed dynamic risk assessments for each patient. These included moving and handling, violence and aggression and safeguarding. However, some staff felt they did not have the appropriate level of training to evaluate risks and manage patients that were experiencing a mental health crisis.

The electronic patient record (EPR) contained protocols and flow charts for specific conditions such as head injuries. Staff were able to make an onward referral using the EPR, for example to a patient’s GP if they had identified a patient at risk of falls.

Staff had access to the SCAS urgent care and clinical support desks which were staffed by clinicians if they required additional clinical guidance. The support provided included shared decision making, help with alternative care pathways, support to crews on scene, clinical referrals and patient follow ups and discharge advice. This was particularly useful for newly qualified paramedics and for emergency care assistants. Crews said this mostly worked well but out of hours it could sometimes be hard to get immediate support.

Staff used the National Early Warning Score (NEWS2) tool, a system for scoring physiological measurements in adults, to clinically observe and promptly identify changes in the patient’s condition. Data was recorded into the electronic patient record and shared with other healthcare providers.

Where a patient’s condition suddenly deteriorated and a crew on scene needed additional help, a request was made via the emergency control centre and an additional resource was dispatched urgently.

When seriously ill or very unstable patients were conveyed to hospital, the crews could pre alert the hospital’s emergency department prior to their arrival. This ensured the patient could be transferred to the hospital’s care with the minimum of delay.

Patients arriving at the department by ambulance remained in the care of the ambulance staff until they could be handed over to the care of hospital staff. A member of the ambulance crew remained with the patient at all times, and there was on-going monitoring of observations with an electronic record of the care maintained.

When the clinical decision was made not to convey a patient to hospital, staff told us they provided advice tailored to the patient's specific situation. Guidance would be given on monitoring symptoms, when to seek further help if symptoms worsen or new symptoms develop, and how to access alternative care options if this was appropriate.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We inspected 15 ambulance resources centres across the South Central Ambulance Service (SCAS) patch. These varied in size and age, some stations were small, housing only a few vehicles and staff, while others were larger, acting as operational hubs with extensive facilities and a larger workforce. Some stations had garages in which vehicles were stored when not in use. Other stations kept vehicles on forecourts either at the front or back of the premises.

All stations were secure, with entry doors requiring a staff pass to be able to access. This meant only authorised people could enter the station. Stations had CCTV cameras which monitored certain areas for security purposes. Station bases had staff locker facilities, showers, toilets and kitchen/mess areas available for staff to use. Facilities were clutter-free and clean. There had been investment in stations since the last inspection improve facilities including updates to storage areas and staff changing areas.

We inspected 18 ambulances across the SCAS patch. All were clean, but inconsistent layouts were seen, and vehicles tended to be overstocked with consumables. This could be a potential safety issue, as it could make locating and accessing items quickly during an emergency harder. It also increased the risk of supplies expiring before they could be used, both wasting resources and increasing the risk of expired items inadvertently being used.This had been highlighted by the service and a quality improvement project started to address these issues.

Vehicles were variable in age and mileage, which was resulting in mechanical issues and vehicles being taken off road to repair. SCAS were in the process of replacing vehicles, as new vehicles arrived, older ones were being decommissioned, and this was lessening the issues that had been seen with an aging fleet.

SCAS had introduced 12 hours per day fleet provision at larger stations, allowing servicing and minor vehicle repairs to be completed on site. This initiative helped ensure vehicles could return to service more quickly, improving operational efficiency and response capacity.

All stations had make ready teams. These teams were responsible for ensuring ambulances and other emergency vehicles were cleaned, restocked with essential supplies and equipment, and fully operational before each shift. These teams were employed by a service partner rather than SCAS but worked closely with SCAS personnel. SCAS staff reported good working relationships with the make ready teams, with minimum issues, but when issues did arise they would be sorted quickly and efficiently.

Equipment and consumables were stored appropriately. Equipment was available to meet patient needs, for example defibrillator and suction machines, and the emergency vehicle trolleys could carry patients with a high body mass index. Safety checks were performed on emergency equipment according to policy. Equipment was serviced, maintained and records kept ensuring quality of the service, with a central team being responsible for this.

The service made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective training, support, supervision and development.

While the service demonstrated strong commitment to staffing, induction, and professional development, there seemed to be a disconnect between clinical focus and operational delivery in ensuring clinical effectiveness. There was an absence of a structured clinical supervision framework, no evidence clinical updates were read and embedded, and limited integration between the education team and operational teams. There were gaps in ensuring clinical standards and updates were adhered to, no consistent approach to sharing updates and learning from patient safety incidents, regulation 28 prevention of future death reports and national learning, and how evaluation of new practices had been embedded. Without a cohesive strategy to bridge these gaps, the organisation risked compromising the quality and consistency of patient care, particularly in high-pressure environments.

All staff with professional qualifications were subject to pre-employment checks to ensure their registration was active and unrestricted. New staff underwent a comprehensive induction programme tailored to their role, including both corporate and local orientation. This involved e-learning and face-to-face training, which staff reported as effective and supportive in preparing them for their responsibilities.

For the past two years, the service had operated under sustained pressure, predominantly at Resource Escalation Action Plan (REAP) levels 3 or 4, indicating major or extreme operational strain. Staff described increased workloads, stress, and fatigue during this period which impacted their ability to deliver safe care and treatment. Contributing factors to high operational pressure, included high service demand, delayed hospital handovers, and a reduced ambulance fleet. To help mitigate these pressures, SCAS engaged third-party providers to support emergency response capacity. At the time of inspection, SCAS had moved to REAP level 2, reflecting moderate pressure. Staff noted this reduction had a positive impact on their ability to deliver care safely and effectively.

The service was fully staffed with qualified, skilled, and experienced personnel. Sickness and turnover rates were 5% and 7% respectively—both below NHS averages. Ambulance crews were composed of various roles, including paramedics, associate emergency care assistants, and ambulance nurses, working collaboratively within their clinical scope.

Local managers emphasised the goal of ensuring every crew included a qualified paramedic. Progress was evident as the proportion of category 1 calls without a paramedic had decreased from 9.3% at the last inspection to currently 5% (data derived from April 2024 to March 2025), and category 2 calls without a paramedic now stood at 14%. However, if other clinical registrants such as ambulance nurses, who could deliver the same advanced assessment and treatment as paramedics, were included in the figures the category 1 calls proportion decreased to 1.9% and category 2 calls to 5.3%.

Mandatory training was provided with protected time for completion. Overall compliance among operational staff was 88%, though 17 out of the 23, 22 out of 23 and 11 out of 17 modules required by registered clinical, non-registered clinical and non-clinical staff respectively fell short of the 95% trust target. Notably, mental health training had the lowest compliance at 75%, followed by manual handling (79%) and conflict resolution (80%). Resuscitation training modules averaged 83% compliance. End-of-life training was suspended pending policy updates. We were told new training materials would be launched later in the year, but no set date was given. Oliver McGowan elearning (learning disability and autism) was completed with compliance rate of 94% across the operational staff. Therefore, mandatory training continued to not be optimal. It was acknowledged that the high REAP levels likely impacted the ability to schedule face-to-face training. It was also noted that SCAS’s 95% compliance target exceeds that of many NHS organisations.

Although mental health and learning disability training were part of the staff’s mandatory training, staff felt it was not robust enough for patients they cared for in the community and felt they would benefit from further learning and support on these topics.

The medical director was the end-of-life clinical lead. However, there was no steering group to ensure the service had oversight and were providing high-quality care for patients nearing the end of their lives, whilst supporting their families.Training for staff was limited as the end-of-life mandatory training had been suspended while subject matter experts updated the relevant policies and training materials. We were not given a date when the new training would be launched.

The education team had training material for operational staff on when resuscitation could be discontinued and what needed to be in place for this to occur, such as a do not attempt cardiopulmonary resuscitation (DNACPR) decision or recommended summary plan for emergency care and treatment (ReSPECT) form. We were not told how many staff had received this training and refresher training on this topic. However, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines, which were available to all paramedics, gave guidance regarding DNACPR decisions.

Emergency drivers received specific training, with additional support provided following incidents or concerns.

Crews were assigned to teams led by a team leader and supported by a clinical team educator (CTE), who provided clinical supervision, mentorship, and professional development mainly for the Newly Qualified Paramedics (NQPs).

NQPs were now well-supported, with CTEs monitoring their practice. The NQPs acted as a third crew members until their competencies were signed off. CTEs continued to monitor their clinical practice for two years post sign off. SCAS also supported student paramedics through an apprenticeship model, which was positively received.

Qualified clinical staff were expected to maintain their skills through ongoing education, simulations, and updates from SCAS and the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines. Teams received five hours of protected team time every 15–17 weeks, used for updates, training, and team cohesion. These sessions were facilitated by the team leader and the clinical team educator (CTE) and were greatly valued by teams. However, they were not formally structured or seen as dedicated education time by the organisation.

Despite these efforts, SCAS lacked a formal organisational framework for consistent clinical supervision across face-to-face and remote care. Informal clinical conversations were common and were considered a form of supervision by the service.

Annual appraisals were completed for 90% of operational staff. These appraisals included performance discussions and training needs but did not incorporate observational ride outs with the staff member on ambulance shifts, or direct clinical observation beyond the NQP stage. CTEs reported limited involvement in ride outs with more experienced staff.

The education and training team was responsible for delivering training and supporting staff development. However, when talking to operational staff it was difficult to see how they efficiently integrated with frontline operations to uphold clinical standards and maintain clinical oversight.

From discussions with operational staff, it was evident that while performance was tracked and monitored, clinical oversight at both local and trust levels lacked clarity. There were gaps in ensuring adherence to clinical standards and updates, inconsistent sharing of learning from incidents and national reports, and limited evaluation of new practices.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Improvement in infection prevention and control were found at this assessment. All ambulance resource centres we inspected were visibly clean and had suitable furnishings which were clean and well-maintained, with major improvements in cleanliness seen at North Harbour resource centre. Cleaning equipment was stored securely in locked cupboards. Cleaning records were up-to-date and showed that all resource centres were cleaned regularly.

The make ready team were responsible for the cleaning of vehicles and equipment, and the storage of equipment and consumables. All vehicles inspected were visibly clean and equipped with visibly clean equipment, clean and available linen, hand gel, personal protective equipment (PPE) such as aprons and gloves, and decontamination wipes.

Routine cleaning of ambulances between patients was the responsibility of the crew. We observed crews thoroughly cleaning the inside of vehicles outside of emergency departments before going to their next patient. Staff explained that if an ambulance became heavily contaminated, crews would return to base, and it would be taken out of service until it had been cleaned. Suitable clinical waste bags for infectious clinical materials were available on vehicles.

Vehicles were deep cleaned to a schedule or sooner if heavily contaminated. This was done by the make ready team. Local managers had oversight of the deep cleaning schedule and kept records for audit purposes.

Ambulance crews attending emergency departments were bare below the elbow and wearing the correct personal protective equipment, including masks and gloves, at the right time. Staff mostly demonstrated good hand hygiene practice in line with national guidance.

Staff maintained the cleanliness of their own uniform as per trust policy and explained if their uniform became severely soiled or contaminated it would be disposed of in the appropriate waste bin and a replacement requested.

SCAS ran a vaccination programme, including vaccinations for influenza and COVID-19, to protect staff, and reduce the spread of infectious diseases within the workplace and community.

Staff disposed of clinical waste safely, with clinical waste being stored and collected at the stations. Sharp bins were used on the vehicles to safely dispose of needles, syringes and other sharp medical instruments. However, we found 5 sharp bins in use that had not be dated on assembly. Sharp bins need to be disposed of after 3 months of use, or according to manufacturer’s guidelines, to help prevent injuries and the spread of infection. Without dating the sharp bins, the age of the container could not be tracked and compliance with waste management regulations could not be ensured.

Audits were used to monitor and improve compliance with infection prevention and control (IPC) standards. This included hand hygiene audits and environmental IPC audits. When issues were found actions were recommended, to be completed in a set timeframe, and then a re-audit was used to ensure improvement was seen. Data reviewed for the months Feb to Apr 2025 indicated that audits were used but lacked consistency in their completion.

Infection Prevention and Control (IPC) training formed part of the trust’s mandatory training programme. IPC Level 1 training had been completed by 95% of operational staff, meeting the trust’s compliance target of 95%. However, IPC Level 2 training had been completed by only 88% of staff, falling short of the required threshold.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was a lack of appropriate and effective systems to ensure clinical oversight of controlled drugs.

We were told by operational staff that vehicles were regularly deployed without morphine, usually as a result of the vehicle having the morphine medication taken off prior to going to external workshops and then being returned to a different station after the work. This had resulted in vehicles regularly sent out without morphine medication although other forms of pain relief were available on the vehicle. Ambulance crews felt, in their opinion, this had resulted in compromised treatment and quality of care they could give to patients. We saw vehicles at emergency departments that had no morphine available to crews, staff told us they felt exposed with regards to the ability to provide reasonable and appropriate options for pain relief.

We were told the issue had arisen due to a change in the management and process of storage of these medicines when vehicles were off the road. Issues were flagged by ambulance crews and at the time of the inspection this was a known issue by the pharmacy team. It had been recognised by the pharmacy team that the change in process might lead to problems with the storage and availability of morphine on vehicles, and this had been entered on the pharmacy risk register. A standard operating procedure had been written, however, this had not been implemented at the time of inspection, several months after the concerns had been raised. We were told by the pharmacy team that a temporary system had been put in place to mitigate issues whilst the new system was being developed and rolled out. However, at the time of inspection, vehicles were still in service without morphine available for crews to use, and crews could not direct us to information being sent about this issue, or any addition training being given regarding alternative pain pathways to use if morphine was found not to be on the vehicle. The trust felt additional training had not been required as guidance on all options of analgesia (pain relief) was available to paramedics via the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance.

Data provided by the trust showed there had been no significant change in morphine administration between pre and post the change in process, and there had been no patient complaints regarding analgesia (pain killers) not being available.

Following the temporary change there had been two reported incidents of morphine not being unavailable on the vehicle, neither reported incident was at the point of care.

Information taken from the pharmacy risk register highlighted the trust had recognised that a vehicle returning to active duty without replenishing its morphine stock might result in patients not receiving essential pain relief when needed, and this could result in compromised treatment, potential harm to patients, and reduced quality of care.

When vehicles were taken off road, usually for repair, only morphine was taken off the vehicle. Other controlled drugs (controlled drugs, CDs, are medicines requiring more control due to their potential for abuse), such as diazepam ampoules and oramorph, were left on the vehicle and accessible to unauthorised personnel. These types of CDs were stored in response bags which were standard on each vehicle, including vehicles which were not paramedic staffed, meaning non-paramedics were having access to controlled drugs, along with the make ready staff.

Controlled drugs were stored safely and securely on ambulance resource centres with access restricted to authorised staff at ambulance stations. Checks were undertaken and recorded by two authorised staff at least once a day. Trust wide controlled drug audits were undertaken by the pharmacy team to ensure safe storage, recording and destruction. Any identified discrepancies or issues were reported directly to the station with advice and action agreed to ensure CDs were stored and recorded following trust policy and procedure.

A member of the trust pharmacy team had visited every station to look at the safe and secure handling of medicines which was part of the future business planning for safe medicine storage. There had been some storage space issues at some of the ambulance resource centres but overall the review found medicines were stored and managed neatly, safely and securely with access only to authorised staff.

Staff told us they had access to relevant medicine policies, procedures and guidelines including a trust medicine formulary. The availability of standard medicine protocols and checklists helped to ensure there was consistency and therefore reduced the risk of any errors.

The trust had up to date patient group directions (PGD’s) which are written instructions for the administration of authorised medicines to a group of patients. There was a well-established PGD group in place to review all the PGDs. This meant that medicines were administered to patients by staff with the legal authority to do so.

Medical gases were stored safely and securely at all locations visited. There was clear segregation between full and empty cylinders. Warning signs were visible to ensure people were aware and to ensure safety around medical gases.

A new pharmacy hub was operational from December 2023 with new packing processes introduced in November 2024. This new facility gave increased space for staff and safer medicine storage. We were shown the checking process to ensure medicines were safe to use and were within date before being packed into medicine bags. A team of pharmacy support workers prepared the medicine bags however we were told that more pharmacy technicians were needed to check the completed bags. The medicine bags were tagged and sealed to ensure safety and security. Each bag was coded so that its location was easily tracked. Returned medicine bags were ‘red’ tagged to identify they required replenishing. Pharmacy staff reported that the system worked well. Any errors or near misses with this process were reported and action taken to ensure lessons were learnt. However, ambulance crews had been raising concerns about controlled drugs and issues remained.

We were shown a pathway for the distribution of medicine bags from the pharmacy hub to ambulance stations to ensure stocks of medicines were available. However, at one station we were shown they did not have enough supplies of one of the medicine bags which was partly due to the location being used as a central medicine collection point for other stations. Therefore, there was a potential risk of medicines not being available to treat patients. Following the inspection immediate action was taken to increase stock levels to that location.

Staff told us they received updates on medicines, including training refreshers, alerts, and reminders to complete relevant e-learning modules. While medicines management training was described as compulsory, several staff noted that the content was more hospital-focused and not sufficiently tailored to the ambulance setting, which they felt would have been more beneficial. When we requested mandatory training compliance rates following the inspection, medicines management was not listed among the mandatory training modules for operational staff. As a result, we were unable to determine the overall completion rates for medicines management training.

Any reported medicine incidents with actions and learning were shared with relevant staff through clinical memos, emails and briefings.

The service used audit to ensure medicines were safely administered. Action and recommendations were published if issues where found. And to make sure good practice was followed. For example, pain relief administration had been audited by the pharmacy team to seek assurance that patients were receiving appropriate pain-relieving treatment. However, this audit was comparing data from January to July 2022 against data collected in February 2024 before issues with morphine on vehicles had become an issue.