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BBC Panorama – ‘Casualties’
Monday 17 January 2000
Reporter David Rose, Producer Kiran Soni

Below are links to items pertaining to the above Panorama documentary.

Programme preview
Transcript of documentary

'What you said' - comments from the Panorama website
Statement from reporter David Rose
Statement from the Ambulance Service Association (17/01/2000)
Letter on behalf of BBC Director General(14/02/2000)
2nd Statement from the ASA (15/02/2000) *requires Adobe Acrobat Reader to open pdf file

Panorama 'Casualties' Preview

The text below is taken from the Panorama website previewing the 'Casualties' documentary (http://www.bbc.co.uk/panorama):

"Panorama reveals that shortcomings in the ambulance service are costing thousands of lives each year. We also discover huge regional discrepancies in the care paramedics provide, which means your chances of surviving a heart attack or a car crash may well depend on which county you happen to be in. There is concern within the medical profession that the training for paramedics is inadequate. The standard classroom training for paramedics lasts only 6 weeks - much less than nurses. After a short period attached to a hospital, paramedics then go out on the road - on probation- but required to administer vital treatments which a doctor would only be allowed to give after several years.

The most crucial of all the skills paramedics need to learn is accurately to assess a critically ill patient. They have to be able to tell the difference between conditions which may have similar symptoms but require completely different treatments. Incidents investigated by Panorama reveal that paramedics do make terrible misjudgements with fatal consequences.

In one tragic case an ambulance was called out to a woman sprawled out on a street. The paramedic decided she was drunk, gave her a slap to bring her round and sent her home in a police car. In fact the woman had been attacked, and two men are awaiting trial for her alleged murder. She died from head injuries a few hours later. Her children Kelly and Patrick Delaney are devastated. "She's gone through that attack, and then the people who've come to save her call her a drunk, slander and negligence - how can we ever live with that?" said Patrick. It is not just poor training that is the problem. There is no consistency across the country about the types of lifesaving techniques paramedics can employ. Victims of impact accidents like car crashes may sustain a punctured lung. This can lead to a life threatening build up of pressure in the chest cavity leaving the victim only minutes to live.

But the situation can be transformed if a relatively simple technique is employed quickly. A needle is inserted to release the build up of pressure in the chest cavity and the patient's condition rapidly improves. Depending on where you suffer a punctured lung, your paramedic may or may not be allowed to use this procedure to save your life.

Regional variations in response times
Panorama also investigates why there is such a wide variation in ambulance response times - the time it takes them to reach a victim following the 999 call - across the country. The Department of Health has set demanding targets for improvement but most ambulance services are not coming close to meeting them. Staffordshire Ambulance Service is a notable exception and a model of good practice. Despite hard evidence of success in Staffordshire, Chief Executive Roger Thayne says he has been vilified by his peers, wrongly accused of fiddling his figures. He says he has felt like "public enemy number one of the ASA" at times. But independent research has shown his system - which is based on having the right number of ambulances in the right place at the right time - is working.

Barry Johns, Vice President of the Ambulance Service Association admits to shortcomings in the ambulance service. Barry Johns also tells Panorama "Some services don't use certain skills, use certain drugs. Currently it's variable and I think it's that variability has been a strength, but also that strength has got to make sure that everybody has advantage to best practice The ASA is the body which oversees the 36 ambulance services that operate in the UK at a regional level and is responsible for promoting best practice within each service. "

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A statement from Reporter David Rose.

Panorama Casualties 17.1.00

I'm very sorry that some viewers, particularly paramedics, construed the programme as an attack on paramedics as individuals. Let me state as explicitly as I can: I, together with my colleagues in the production team, recognise that most paramedics are very dedicated people, who have to put up with conditions and pay that many would find quite unacceptable, and who often experience abuse and worse from those they are trying to save. And often, they do save lives.
The point of the programme was not to criticise these people, but the system in which they are forced to work. This is a system in which the ASA vice president, Barry Johns, could state to Panorama that many services do not deliver best practice; a system in which Mike Handy of East Midlands could turn away from the camera and refuse to answer why a lifesaving drug is available in part of his service area and not in the rest. Above all, it is a system in which the minimum requirements fall seriously below the standards of paramedic education elsewhere.
My comment that technicians are 'basically drivers with first aid' seems to have caused more anger than anything else. Of course, there are many technicians who have voluntarily gone well beyond this standard: they have, for example, been trained to use defibrillators, and to administer drugs such as salbutamol. However, these 'add ons' are not included in the IHCD technician syllabus, which, tellingly perhaps, comes under the title 'Basic Ambulance Aid'. Looked at in detail, the course does amount to advanced first aid. It includes the techniques of CPR, splinting, bandaging, oxygen therapy and entonox pain relief. It does not include any invasive therapy or advanced life support techniques. Useful as technician experience will undoubtedly be for the fledging paramedic, in no sense is the working technician being 'trained' as a paramedic.
Similarly: while on the road experience after the paramedic training course is of course vital, it doesn't - as the programme stated - equate to the intensive continuing education of a nursing degree. I am aware of the new degree courses at Herts and Sheffield. The problem is: as yet, there is no place for graduates within the UK ambulance system. Moreover, when the Government announced the target of a paramedic on every ambulance, the abolition of negative marking for the paramedic tests actually reduced qualification standards. At a meeting of the ASA education and training committee in September 1999, Mike Willis, chief executive of the West Country ambulance trust, said half the paramedics trying to transfer to his service from elsewhere were 'failing their assessments on national criteria' - as the meeting's minutes clearly state.
It's claimed we took three exceptional cases out of context. Well, within a few hours of the programme finishing, we had received details via the website of several further, equally disturbing cases, and we already knew of two or three more. One of the problems of UK ambulance care is that there isn't any effective clinical audit of what happens. But as the programme showed, academic research backs the proposition that pre-hospital care is not as good as it might be - however hard paramedics undoubtedly try.
The programme began by claiming that the shortcomings of the ambulance service and of paramedic training cost thousands of lives each year. It backed that claim by examining lives lost through the following: lack of training in general, and in the skills needed to intubate semiconscious patients in particular; the failure of some services to provide treatments which are available elsewhere; and in the failure of the ASA to acknowledge Staffordshire's dramatic achievements in response times, and thus to emulate its higher cardiac survival rate.
There are several culprits in this: the failure to fund training centrally and the sluggishness of ambulance management, to name but two. But these avoidable deaths ought to be the starting point for debate.
David Rose

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A Statement from the Ambulance Service Association

Panorama programme
'shallow, selective and misleading'says ASA

Panorama's programme on ambulance paramedics was a 'missed opportunity to inform the public' the Ambulance Service Association said today.
The programme began with a deliberately misleading statement - put to members of the public in Bristol - that paramedics only trained for six weeks.
"No wonder the public were amazed," says an ASA spokesman. "It simply isn't true."
In fact a paramedic trains for nearly three years, including two 12-month periods of on the job training under supervision. Nurse's train for three years and doctors for seven, but the different professionals shouldn't be compared because their training covers different skills. Paramedics are trained in a specific series of life-saving skills, not the full range of care needed by a nurse or doctor, who practice in very different circumstances.
The programme selected carefully from two interviews with leading Chief Executives of Ambulance Trusts, using just a couple of minutes in total from interviews which both lasted over an hour with Barry Johns of the ASA and Mike Handy of East Midlands.
It claimed 'thousands of lives could be saved' by improved paramedic training, but presented no evidence for that statement apart from anecdotes.
It focused on four cases of tragedies, which involved paramedics over the last five years. Ambulance paramedics are called to between two and three million accidents and emergencies every single year. The ASA can provide dozens of examples of lives saved by paramedics within the last few weeks.
Panorama used one small scale study to show that out of 179 cases of serious injuries one in 20 who died might have been saved. This is the same level as occurs in hospital, with doctors looking after the patient. It proves nothing about the skills of paramedics.
Paramedic training has improved dramatically over the last ten years and the agreement by Parliament to giving paramedics state-registered status was achieved following a petition initiated by the ASA itself.
The programme was littered with inaccuracies. Paramedics are keen to use some of the new drugs, but they cannot do so if the law says they cannot. All local protocols are agreed by committees of hospital consultants.
All ambulance services are working with the ASA to improve protocols all the time and the ASA is driving through a new enhanced training programme which will bring in more skills to further develop the way paramedics care for critically ill patients.
The ASA embraces change. It represents all ambulance services and is totally committed to improving quality wherever possible, and in finding better ways of delivering lifesaving care to patients. Every day of the year paramedics save lives in this country.
In the end this was a deeply disappointing programme because it failed to inform the public about the great improvements that have been made in pre-hospital emergency care over recent years.
By choosing instead selective reporting and sensationalism it will unnecessarily alarm the public about a service they should take great pride in, and which they can feel very confident about.
Issued by the ASA on 17.1.2000

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