Ambulance trust ‘covered up evidence about mistakes by paramedics linked to deaths of 90 patients’ 


An NHS ambulance service misled coroners by changing documents and witness statements about deaths linked to how it treated patients, it has been reported. 

North East Ambulance Service (NEAS) has been accused of doctoring multiple reports and keeping families in the dark about exactly how their loved ones died.

It is claimed that coroners were not given key evidence and that senior managers at the service edited witness statements that had been requested, in some cases making it look like no mistakes had been made.

According to The Sunday Times, whistleblowers say this could have happened in as many as 90 cases in the last three years, with the whistleblowers offered non-disclosure agreements worth more than £40,000 by the trust.

Whistleblowers say that despite a report by auditing firm AuditOne, which was done in 2020 and shared with the chief executive of the trust and other senior staff, the problem remains.

The report, which took 30 cases from 2019 to February 2020, and looked at six in depth, found NEAS was not handing over documents to the coroner properly.

North East Ambulance Service was found to have changed documents and witness statements about deaths linked to how it treated patients (stock image)

Among the cases it looked at are those involving a 17-year-old girl who was not given proper life saving treatment after she hanged herself, a 32-year-old man who died after he was left waiting more than an hour for an ambulance and a 62-year-old man who died when his oxygen machine cut out during a power cut. 

In all these cases NEAS was found to have edited or withheld key information from the coroner and the families of those who had passed away.

The AuditOne report said: ‘It is not for the trust to determine whether to disclose a document. If it is relevant to the death it must be disclosed.’ 

One source told the Sunday Times there are concerns about the deaths of dozens of more people since the report and that the trust had put its reputation ‘ahead of everything else – even ahead of bereaved families’.

NEAS said it had made ‘significant improvements’ as the result of a ‘task-and-finish group’ which wrapped up last year.

Dr Matthew Beattie, medical director at NEAS, told the Sunday Times that concerns had been raised by staff in 2019. 

In response a ‘task and finish group’ was set up and ‘concluded in January 2021 with these actions completed and assurances provided to our board of directors that significant improvement had been achieved.’

He added that concerns that have been raised involving patients who died after then were due to ‘minor issues’ of procedure and policy being followed and did not affect any families.

Among the deaths investigated in the report is the tragic case of Quinn Beadle, a 17-year-old girl who took her own life near her family’s home in Shildon, County Durham, in December 2018. 

An internal investigation would later find an ambulance worker who was called to the scene did not clear her airway and failed to perform proper resuscitation methods despite an electrocardiogram heart monitor (ECG) showing no evidence she had ‘flatlined’.

The fact an investigation was taking place was not relayed to the coroner until after it had finished, and when the coroner requested the report, managers at NEAS decided to change it to omit key details. 

These included references to the ECG, failure to clear her airway and provide proper life support, a well as a comment from the paramedic themselves admitting they should have done this.

Managers present at the meeting, which had no minutes or documentation, then decided to add ‘the decision not to start advanced life support upon reflection was the correct decision’, the opposite of what the paramedic had said.

Quinn Beadle, pictured here with her older brother Dyllon Milburn, died after taking her own life in 2018. The report found a statement from the paramedic who treated her was altered to make it look like there were no mistakes in her treatment

Quinn Beadle, pictured here with her older brother Dyllon Milburn, died after taking her own life in 2018. The report found a statement from the paramedic who treated her was altered to make it look like there were no mistakes in her treatment

In the report, which has been seen by The Sunday Times, AuditOne said the changes ‘removed a critical fact and changed the conclusions so dramatically that it did not reflect the findings within the report, nor the original conclusions drawn by [the clinician]. 

‘The most crucial part of the new conclusions was in direct contrast to the original conclusions.’

It added that when asked about these changes, the paramedic whose statement was changed felt unable to go against this as they were made by senior members of staff.

The coroner was unhappy with the doctored report and adjourned the hearing to allow for further investigations, before later telling the family NEAS had tried to turn ‘black into white’.

Her older brother, Dyllon Milburn, took his own life months after this was revealed, after being ‘haunted’ by the claims his sister could have been saved. 

Tracey Beadle, Quinn’s mother, told the Sunday Times the trust had ‘just covered it up and covered it up’.

‘You just can’t believe that a service that’s supposed to look after people could lie to you like that.’

NEAS told the newspaper it had disclosed all evidence to the coroner before the adjourned inquest and an independent investigation was commissioned to look into what happened.

It added that while the coroner had been ‘critical’ of the trust, which operates across Northumberland, Tyne and Wear, County Durham, Darlington and Teesside, ‘he was satisfied the systems we put in place would prevent a repetition’.

Helen Ray, chief executive of North East Ambulance Service, said: ‘We accept that there were historical failings and we have listened and acted upon the concerns raised by staff of the quality and timeliness of documents disclosed to coroners.

‘Utmost in our mind are the families and we unreservedly apologise for the distress we have caused to them.

‘The claims made that we continue to fail in respect of disclosure are incorrect. A member of staff does continue to have concerns, but we have continued to act when concerns are raised.

‘We have reaudited our process, have discussed with coroners and with the CQC and have embedded regular reviews to ensure these issues cannot reoccur. We are confident that the system in place is robust.

‘The Care Quality Commission formally responded in late 2020 to confirm they had closed the matter with no further action deemed necessary. Northumbria Police, who were involved when a member of staff was dissatisfied with our actions, have also confirmed this matter is closed with no action taken on the basis there was no evidence to support the allegations put to them.

‘Many of the cases passed to coroners relate to the timely response of an ambulance to an emergency call. It has been widely reported that the delays in reaching patients have become an issue across the country, not just in the North East. We are working closely with our commissioners, following a significant investment in our service over the next 12 months, to improve our response performance.’

University student, 21, whose 17-year-old sister hanged herself took his own life ten months later because he was ‘haunted’ by claims paramedic could have saved her, inquest hears

By Tom Pyman for MailOnline

A university student whose teenage sister hanged herself took his own life less than a year later because he was ‘haunted’ by claims a paramedic could have saved her life, an inquest heard.

Dyllon Milburn, 21, was already devastated over the death of Quinn Beadle, 17, but then learned of an investigation into claims the ambulanceman called to the scene had pronounced her dead ‘too quickly’ without making any attempt to revive her.

As enquiries continued into the tragedy, Dyllon, from Shildon, Co Durham, who had taken a year off college became tormented by what his family called ‘a wicked cover up.’

Just ten months after his sister’s death and less than a month after reading the report about the paramedic’s conduct, he was found hanged in the back garden at his student digs in Manchester.

Dyllon, 21, (pictured above) took his own life 10 months after his little sister Quinn's death. His parents say the world was 'too cruel' for him after her suicide

Dyllon, 21, (pictured above) took his own life 10 months after his little sister Quinn’s death. His parents say the world was ‘too cruel’ for him after her suicide

The tragic scenario began in December 2018 when Quinn – described as a ‘generous, kind 17-year-old with boundless energy’ – was found hanged from a tree near her home following a battle against depression.

Initially the death was treated as an ‘open and closed case’ and Manchester Metropolitan University undergraduate Dyllon and his parents set up a charity to help other families grieving by the suicide of loved ones.

But unbeknownst to them, the North East Ambulance Service had begun an internal investigation after it emerged the solo paramedic called to the scene told two police officers attempting CPR: ‘You can stop now, she’s gone’ after simply looking into Quinn’s eyes with a pencil torch.

In April 2019, an inquest into Quinn’s death was due to be held, but was then delayed after Dyllon and his family learned of the investigation into the unnamed paramedic – known only as GW.

At the Manchester hearing his mother Tracey Beadle said: ‘After Quinn died, we set up the charity, Quinn’s Retreat, to help other people who have been bereaved by suicide and provide them with short breaks.

Dyllon Milburn

Quinn Beadle

Dyllon Milburn (left) ‘didn’t realise’ sister Quinn Beadle (right) was his best friend until after her death, their mother said

‘Dyllon was the leading force in setting the charity up and was a very proud trustee and we put on a charity event. We turned the place where Quinn took her life into a little garden for the community.

‘But Dyllon then read the independent report into Quinn’s death and he told me it was the things that he read in the report was haunting him.

‘The report showed the wrongdoing of the paramedic who was the first on the scene the night we lost Quinn. The report said Quinn had been left face down in the mud and Dyllon couldn’t get it out of his mind.

‘He couldn’t believe anyone would do that to his little sister and he kept coming back to that. He said he didn’t realise Quinn was his best friend until we lost her. It was eating him up inside that someone could do that to her.

‘At the time when we were preparing for Quinn’s inquest, we didn’t know anything about what had happened to her and we thought it would be open and closed and we only found out two days before the inquest that anything had gone wrong on the evening she died.’

The siblings, pictured here as children, were described by their parents Tracey and David Beadle as 'special' and 'amazing children'

The siblings, pictured here as children, were described by their parents Tracey and David Beadle as ‘special’ and ‘amazing children’

The tragic scenario began in December 2018 when Quinn (pictured with her brother as children) - described as a 'generous, kind 17-year-old with boundless energy' - was found hanged from a tree near her home following a battle against depression

The tragic scenario began in December 2018 when Quinn (pictured with her brother as children) – described as a ‘generous, kind 17-year-old with boundless energy’ – was found hanged from a tree near her home following a battle against depression

An independent report was ordered after her inquest was delayed and it was later produced on September 23, 2019.

Dyllon hanged himself on October 8. He himself had a history of anxiety and depression and had been prescribed anti depressants.

His mother added: ‘We were messaging the previous evening. At the end of every phone call, he said he loved us. If you were having a text conversation, he would normally say, ‘I love you lots.’

‘He was on and off his medication. I knew that he was feeling really low and suicide may have been on his mind. I did discuss it with him. I tried unsuccessfully to get him to go into counselling. He just said he wasn’t ready for it.

‘Dyllon was amazing. He was larger than life. He was so kind and caring. He loved the world and everything in it. He would always tell you that he loved you. He would give you the best hugs. He was just wonderful.’

A coroner said: 'Dyllon (right) was a loving person and the leading force of the charity set up in Quinn's (left) memory to assist those who have gone through similar events'

A coroner said: ‘Dyllon (right) was a loving person and the leading force of the charity set up in Quinn’s (left) memory to assist those who have gone through similar events’

Recording a conclusion of suicide Manchester coroner Zak Golombeck said: ‘There were things in Dyllon’s life that were extremely hard to deal with – most notably the death and the circumstances around the death of his sister, who he loved dearly and they were extremely close.

‘Dyllon was a loving person and the leading force of the charity set up in Quinn’s memory to assist those who have gone through similar events to what Dyllon and his family went through. This shows the type of person that Dyllon was.

‘However, he struggled with his depression despite having a close network of friends and family around him. A report was commissioned into the death of Quinn and this had a profound effect on him particularly as a result of their close relationship as siblings, but also because of the nature of what the report told him. As Tracey put it, it ‘haunted him’.’

When the inquest into Quinn’s death was heard in October 2020, a coroner recorded a narrative verdict saying although the ambulanceman had failed to used a defibrillator upon her, there was a ‘minute chance’ she could have been saved. 

The ambulance service has since apologised.

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