Investigation findings announced

Date: 13 May 2020

east of england ambulance service crest

Ambulance staff will see more support, training and earlier intervention to protect their mental health and wellbeing in and outside work as part of an action plan announced today (13 May 2020) by the East of England Ambulance NHS Trust (EEAST). The plan will address recommendations published today from an independent investigation into three unexpected deaths of ambulance staff in November last year.

The investigation, undertaken by independent investigator Christine Carter began in December 2019 and involved interviewing over 40 witnesses, including the families of the three staff members. The aim was to provide the Trust with:

  • a clear understanding of the events leading to each of these unexpected deaths
  • any associated learning in relation to the management and support of staff within the organisation and
  • any wider organisational learning and development.

The investigation sets out 12 recommendations which have been discussed by the Trust Board. An action plan has been developed and agreed to make sure the recommendations are implemented as quickly as possible.

Acknowledging the investigation and welcoming the recommendations, Dorothy Hosein, EEAST Chief Executive Officer, said:
“Losing three members of our staff in tragic circumstances is extremely sad.  Each of these separate incidents reveals a deeply personal story and a terrible loss with a huge impact on families, close colleagues and across the wider service.

“We all know work and home life are not easily separated. Staff wellbeing is influenced by personal, family and other relationships and experiences, as well as their employment. This has not been reflected in some of our policies and management of issues, which are still too tightly focused on just workplace performance.”

“Every day our staff do fantastic work at the frontline of healthcare and often in very demanding circumstances. That is more true today than ever before. This investigation brings home clearly that the Trust must do more to support the mental health of staff if they suffer problems or anxiety in their private, family or work life.

“I am committed to instilling a culture which sees, respects and cares for all staff as individuals. To do this, we will move fast to improve our well-being policies and practice so they recognise and support the whole person, in and out of uniform.
This will mean taking rapid and robust action to address issues arising in the workplace, and outside of work as well. My aim is for all our managers to listen to and support colleagues and spot any early signs where help might be needed.”

Commenting on the recommendations, Dorothy Hosein said:
"We are already making progress on our action plan to address these recommendations. Half of our actions will be completed by the end of this month, with all the recommendations addressed by the end of September. We will continue to provide regular updates to the Board and online.”

A summary of the recommendations is below, with the full wording available here.


  1. The Trust should produce specific guidance on the management of serious incidents involving the death of a member of staff

  2. Cross-reference new guidance for management of death in service serious incidents with on call systems and guidelines document

  3. Cross-reference new guidance for management of death in service incidents with the Management of Serious Incidents Policy, making specific reference to serious incidents involving death of a staff member.

  4. Guidance for the welfare and management support of staff on sick leave should be included as an appendix in the Sickness Absence Policy (and Disciplinary Policy in relation to the rules of sickness absence applying when a person is suspended and on sick leave).

  5. The Trust should develop guidance for managers regarding supporting staff who are experiencing mental health problems (whether off sick or still at work).

  6. The Trust should develop training for managers in supporting staff with mental health problems – in partnership with specialist mental health professionals, building on the guidance developed under recommendation

  7. The Trust should consider how it can contribute to and learn from the range of suicide prevention strategies and initiatives across its catchment area and incorporate suicide prevention into its strategic goals

  8. The Trust needs to establish a programme of change and development to address sexual harassment and change the behaviours of staff and managers that enable it to thrive. This will require some facilitation and support for the management team to undertake this task.

  9. The Disciplinary Policy should be amended in relation to suspension of staff. The policy should include a clause reflecting the need to undertake a risk assessment at the time the decision to suspend a member of staff is made

  10. The Trust should review its arrangements for first line management support in order to move to a model that provides front line staff with consistent and regular line management support

  11. Senior Operational Managers (Deputy COO and Heads of Operation) should be reminded of their responsibilities under the Duty of Candour Policy to deliver the Duty of Candour message.

  12. The Trust should carefully consider the findings of all current investigations, together with this one to assess any common themes or consistent messages that would suggest the need for remedial actions and further organisational development initiatives.


Notes to editors

  1. The full recommendations from the report are available here.

  2. The Trust’s latest action plan can be found here.
  1. East of England Ambulance Service NHS Trust provides 24 hour, 365 days a year accident and emergency servicesto those in need of emergency medical treatment and transport in Bedfordshire, Hertfordshire, Essex, Norfolk, Suffolk and Cambridgeshire.  We also provide non-emergency patient transport services for patients to and from hospital, treatment centres and other similar facilities.  

    In 2018/19 the Trust received more than one million emergency calls and treated 64,157 people through our Emergency Clinical Advice and Triage Centre. Our resources and teams include more than 4,000 staff and more than 1,500 volunteers; three ambulance operations centres in Bedford, Chelmsford and Norwich, 387 front line ambulances; 178 rapid response vehicles; 175 non-emergency ambulances (PTS and HCRTs vehicles); 46 HART/major incident/resilience vehicles based across more than 130 sites.

  2. EEAST initiated an independent investigation in December 2019 into the circumstances surrounding the unexpected deaths of three staff at EEAST. The purpose of the investigation was to ensure that all appropriate actions were taken and will continue to be taken to ensure the welfare of staff is of the highest priority and to ensure that learning is identified and translated into improvements by the organisation to mitigate the reoccurrence of any similar events.

  3. The independent investigation contains a significant amount of personal details relating to the individual staff members, their families and colleagues. Given this, the decision has been taken on privacy grounds that the full investigation report will not be published by the Trust to protect the families. In the interests of transparency, we have published the full recommendations and the Trust action plan. The Trust has shared the full report with our regulator, the Care Quality Commission, and NHS England / Improvement. We will also share the report with commissioners via the formal Strategic Executive Information System (StEIS) reporting process for serious incidents. The families of the three members of staff have received an individual case specific report, which has been or will be shared with relevant coroners.
  1. The investigation, as reflected in the recommendations, found that the Trust needed to make improvements around guidance, policies and additional training and support for managers and staff. It did not find or recommend any action against named individuals.

For any media enquiries, please contact the EEAST Communications and Engagement team at or on 01763

  • Summary:

    Ambulance staff will see more support, training and early intervention following an independent investigation into three unexpected staff deaths last year.