Duty of Candour Annual Report 2024 - 2025

1 Introduction

All health and social care services in Scotland have responsibilities under The Duty of Candour Procedure (Scotland) Regulations 2018. This is a legal requirement which means that when unintended or unexpected events happen that result in death or harm as defined in the Act, those affected understand what has happened, receive an apology, and that organisations learn how to improve for the future.

An important part of this duty is that Health Boards provide an annual report about how the Duty of Candour responsibilities have been implemented in our services. This report describes how The Scottish Ambulance Service has operationalised the Duty of Candour requirements during the time between 1 April 2024 and 31 March 2025.

2 About the Scottish Ambulance Service

At the frontline of the NHS in Scotland and with over 6,400 members of staff, we provide an emergency ambulance service to a population of 5.4 million people serving all of the Scotland’s mainland and island communities.  We are responsible for a range of services for the people of Scotland from accident and emergency response, to delivering primary care, providing patient transport, dispatching air ambulance and SCOTSTAR support for critical patients, to being a Category 1 responder for national emergencies. 

Last year our Ambulance Control Centre handled 1,066,121 Emergency, Urgent and Unscheduled Care calls, up 0.9% on the previous year and responded to over 542,698 Emergency Incidents, 4.2% more than last year. Our Ambulance Control Centre is augmented by teams of multi-disciplinary clinicians (Paramedics, Nurses, Advanced Practitioners and GP Advisors) within our Integrated Clinical Hub who continue to provide enhanced clinical decision making to ensure patients receive timely and appropriate care that meets their needs.

Last year 22.6% of patients that called 999 were managed without a traditional ambulance response. 158,130 patients were managed by delivering care remotely or by referral to alternative pathways of care. Further information on our activity in 2023-2024 is shown below.

• Calls received: 1,479,244
• Emergency calls received: 1,066,121
• 94.1% of emergency calls answered in 10 seconds
• Total incidents: 815,205
• Emergency incidents: 700,817
• 22.6% of emergency patients managed at point of call (158,130)
• Emergency incidents responded to: 542,698
• 24.7% of emergency patients managed on scene (173,131)
• 47.3% of patients managed without the need to go to hospital (331,261)
• 52.7% of emergency patients taken to hospital
• Special Operations responses: 5,244
• Inter-hospital transfers: 36,322
• Planned patient journeys delivered: 404,939
• Air Ambulance/ScotSTAR missions 4,457 with 3,338 transfers and retrievals
• Our mobile vaccinations units vaccinated over 56,346 people

3 Number and Nature of Duty of Candour incidents

Between 1 April 2024 and 31 March 2025, there were 26 incidents where the Duty of Candour legislation was applicable. These are unintended or unexpected incidents that result in death or harm as defined in the Act, and do not relate directly to the natural course of someone’s illness or underlying condition. In considering these incidents it is often not possible to be certain that the circumstances of the incident had a causal effect in terms of harm, however in the spirit of the legislation we have included cases where we are unable to determine this point fundamentally.

We identify through the significant adverse event review process if there were factors that may have caused or contributed to the event, which helps to identify Duty of Candour incidents.  There may be occasions where Duty of Candour may not be carried out due to lack of contact details of the patient and/or family, or where the principle family contact is through a partner organisation.

4 To what extent did The Service follow the Duty of Candour procedure?

We were compliant with guidance in 22 out of the 26 occasions where Duty of Candour was required. On 15 of those occasions we informed the people affected, apologised to them, and offered to meet with them. On 7 of those occasions we made an attempt to engage with the people affected but were unable to identify a Next of Kin contact. In each case, we reviewed what happened and what went wrong to try and learn for the future.

On 4 occasions we were non-compliant, where it was recorded that contact was not established during the incident review process. We have since updated our systems and processes to clearly outline our duty to engage with people affected, with a view to full compliance in the coming year.

5 Information about our policies and procedures

Every adverse event is reported through our local reporting system as set out in our Adverse Event and Duty of Candour Policy. Through our adverse event management process, we can identify incidents that trigger the Duty of Candour procedure.

Each adverse event is reviewed to understand what happened and how we might improve the care we provide in the future. The level of review depends on a number of factors, including the severity of the consequence of the event as outlined in our policy. However, beyond the duty applied to us within the Act, we apply the principles of open and honest communication that underpin the Duty of Candour legislation to all Significant Adverse Event Reviews carried out within the Service.

Recommendations are made as part of the adverse event review and we develop improvement plans, as incident reviews are taken through our Clinical Governance processes. We track the completion of these actions centrally through our Adverse Event Reporting System.

The method of dialogue used to engage with those parties affected is managed dynamically. As can be expected, the level of engagement and the ways in which we engage with the affected parties can vary, based on individual circumstances. Our principle in engaging with those affected is to do this based on the wishes of those affected. That can include engaging in person, face to face or by phone, in writing or through an appropriately agreed third party. Not only do we seek to engage with the affected parties, we offer those affected the opportunity to influence recommendations for improvement, in order to robustly ensure that as well as being open and honest, we can really ensure that the views of those affected align to agreed improvement actions.

All relevant managers received training on how to manage an adverse event on the reporting system. We know that adverse events can be distressing for staff as well

as people who receive care. We have support available for all staff through our line management structure as well as through Occupational Health Services. This means that staff can contact a confidential telephone line to speak to trained counsellors. We have also developed a wellbeing strategy which we are currently implementing and as part of that we have rolled out trauma risk management (TRIM) for our staff.

6 What has changed as a result?

We have made and are planning a number of changes and improvements following review of our adverse events within 2024-2025 and these are listed below:

Actions relating to Demand and Capacity and Hospital Handover Delays

• Implementation of the SG Guidance: Principles for Safe Transfer to Hospital: Ensuring Timeous Handover of Ambulance Patients. Implementation of actions by NHS Boards is ongoing with communications and local agreed action plans continuing.
• We have engaged with receiving hospitals to ensure a timely admission process is in place for the receiving of time critical patients to the resuscitation department in the Emergency Department.

Actions relating to our Ambulance Control Centre’s (ACCs)

• We confirmed it is now process for a duplicate call to be highlighted to the call handling supervisor to ensure that any missed opportunities for identifying patient deterioration is minimised.
• We clarified the communication and process when updates are being passed between services to avoid delays in call re-priorisation.
• We implemented a process for when calls are initially routed to Police Scotland and also require a response from SAS, that the caller is transferred or the line is cleared to allow SAS to make contact for additional triage or to pass first aid advice in the form of Post Dispatch Instructions.
• We reviewed and tested call triage configuration tables and coding for 999 calls for all chief complaints where patient status is reported to be “not alert”; to ensure appropriate code for clinical acuity is generated.
• We have reviewed the HCP Booking process, including processes for safety netting, welfare checks and escalation requirements.
• We have reviewed the Health Care Professional Booking guide to ensure relevant clinical information in captured.
• We have reviewed processes in place for the supervision, performance management and welfare support of Call Handling staff receiving and actioning 999 calls.
• We have confirmed the process in place that ensures that patients awaiting an emergency ambulance response receive appropriate and timely review, and that where necessary their priority response category is re-considered within the waiting emergency stack during periods of increased demand.
• We have reviewed the requirement for recurrent funding to recruit Clinical Support Advisors, non-registered clinicians who can support the Integrated Clinical Hub and undertake safety netting of patients awaiting an emergency ambulance response.
• We have implemented the deterioration module
• We are reviewing the duplicate call processes to determine if there can be a systems-based way to identify multiple calls for a patient over a short time frame. If so, we will utilitise this function to trigger the ICH to undertake a clinical review.
• We are reviewing call handler guidance for cardiac arrest incidents and the initiation of CPR instructions.
• We have expedited the development of the deterioration/welfare module which increases our capacity to recognise deteriorating patients whilst they are waiting on our ambulance response. 
• The Service should develop updated guidance around safety netting processes, including review of the requirement for enhanced call-back for patients who are vulnerable or at increased risk of deterioration.
• We have considered an increased number of dispatch supervisors on shift for dispatch resilience and to enable dedicated time to report on adverse events, so that learning can take place at the time.
• We have reissued guidance on the lone-worker policy.
• We have reviewed decision-making support available to dispatchers. 
• We are reviewing the process for Safety Netting waiting calls, including ACC capacity and availability of staff to support this function. 
• We provided feedback to NHS24 regarding the correct use and implementation of the NHS24 Process Communications Pack. 
• We are considering developing minimum operating standards for Advanced Practitioner telephone response times and clinical safety netting. 
• We are reviewing the current process in place to prepare for incidents of IT outages.
• We are developing measures and a reporting process to ensure that patients awaiting an emergency ambulance response receive appropriate and timely review and that where necessary are re-prioritised within the waiting emergency stack during periods of increased demand. 
• We provided feedback to the Hospital-at-Home team about the appropriate use of Timed Admissions Bookings.
• We asked the Clinical Response Model Group to review cases.
• We are considering agreeing Integrated Clinical Hub response time standards in order to define best practice and a performance measurement framework.
• We are reviewing the current capacity available for the provision of timely call back and additional clinical assessment of patients awaiting a delayed ambulance response, to enable appropriate safety netting and recognition of deterioration.  
• We are reviewing the response category for 31D04 (previously Red before NCRM) Unconscious or Fainting – Changing Colour, alongside recent historical data to ensure that all MPDS codes associated with this clinical scenario have the most appropriate priority level and management plans.
• We are reviewing the current resource provision and process for dispatch during times of escalated activity, to ensure timely resource checks are carried out in line with organisational guidelines. 
• We are establishing measuring and reporting procedures to ensure that patients awaiting a timed admission ambulance response receive appropriate and timely clinical review, and that where necessary are re-prioritised within the waiting emergency stack during periods of increased demand.
• We are reviewing the current measures for the supervision, performance management and welfare support for Call Handlers.
• We reissued MPDS Practice Guidelines for Protocol 12, Convulsions/Fitting.
• We are carrying out a joint review and update of the “Booking On Guidelines” to ensure clarity around the process of managers booking on and criteria for availability.
• We are reviewing the process for caller cancellation of an ambulance within the National Escalation Plan to ensure appropriate supervisor/clinical input to approval for each acuity level of call.
• We have reviewed the clinical capacity within the ACC to support incoming calls to ensure the safety netting of waiting calls.
• We are implementing an additional level of safety netting for calls within the Integrated Clinical Hub.

Actions relating to Staff Education and Training

• We included the elements of securing patients to trolley cots within our face-to-face Learning in Practice.
• The Learning in Practice for staff has been updated to include manual handling elements.
• We are considering scheduling Learning in Practice for Ambulance Care Assistants.
• We are exploring the potential of an automatic visual warning of acute abnormal ECG results by the defibrillators
• We will complete the review of airway management currently in progress via the Clinical Assurance Group, which should include consideration of airway skills and drills practice requirements. 
• We are reviewing the requirement and process for standardised clinical training regarding the recognition and assessment of Stroke, to include reference to practice standards, guidelines and pathways of care.

Actions relating to frontline operations

• We communicated with all GP Practices and OOH’s (GMEDs) with regards to the booking process for an Emergency Ambulance.
• We collaborated further with GP practices to ensure that Emergency Care Summaries contain up to date and relevant patient information to fully inform practitioners decision making.
• The PNA is reviewed to ensure the advice within the SAS health and safety manual handling guidance is incorporated in the PNA.
• The SAS scheduled care service to review the process where ACAs can access clinical advice and support from a senior clinical decision maker.
• We re-issued the bulletin for staff on utilisation of patient restraint/harness on trolley cots with additional monitoring by operational managers for further incidents or concerns.
• We considered the resilience available within the ambulance fleet in rural areas
• We re-circulated the procedure for requesting the attendance of Police Scotland following a death in the community.
• We are considering ECG interpretation decision making support availability for crews on scene.
• We are reviewing the guidance provided in the Clinical Decision-Making Framework regarding safety netting advice given to patients, to ensure this includes details of worsening symptoms and actions to take.
• We are carrying out a joint review and update of the “Booking On” Guidelines with Operational and ACC management involvement.
• We are considering implementing an updated referral / discharge process within the electronic patient record to guide and support safety netting of patients.
• We are publishing guidance outlining the process and support available to crews attending patients in custody/Prison.
• We are considering the introduction of frontline pregnancy testing functionality.

Actions relating to Clinical Guidelines

• We have issued a National Clinical Bulletin advising reference to ‘Toxbase’ for any patient who has taken an overdose, or has encountered poisonous substances, for both remote consultation and attendance in person.
• We have republished the guidance regarding prof-to-prof calls and the Clinical Decision-Making Framework. 

7 Other information

As required, we have submitted this report to Scottish Ministers and we have also placed it on our website.

If you would like more information about this report, please contact us using these details: sas.corporateaffairs@nhs.scot.