In 2015, the South East Coast Ambulance Service NHS Foundation Trust, which is responsible for sending ambulances in the Kent, Surrey, Sussex, Brighton and North East Hampshire regions, was under investigation for failing to adhere to NHS national response targets. 

Under NHS rules, patients with "life-threatening" conditions should receive an ambulance within eight minutes, whether the call was made to the emergency 999 system or the non-emergency 111 line. 

During a two month period between 20 December 2014 and 24 February 2015, the trust ran a pilot scheme aimed at  gaining more time to assess the severity of a patient's condition. The result of the scheme was that some non-emergency 111 calls - including some relating to "life-threatening" conditions such as strokes and fits - were transferred to the emergency 999 system, thus delaying ambulance dispatch times. 

Up to 20,000 patients were put at risk and at least 11 patient deaths have been linked to the rogue protocols, including a 60 year old man who was forced to wait 35 minutes for an ambulance despite experiencing clear signs of cardiac arrest while on the phone to 111 call handlers. 

Monitor, the health regulator, has recently concluded its investigation and is deeply critical of the trust's "fundamental failings". It concludes that the decision was deliberately made by Paul Sutton, the trust's chief executive, and that he implemented the scheme without discussion with the trust's board, without any risk assessment, and in clear breach of NHS rules. 

A separate inquiry will now be commissioned to investigate the extent of harm caused to patients by the decision to delay ambulance dispatch for thousands of patients with life-threatening conditions. 

Arran Macleod, a clinical negligence solicitor at Penningtons Manches, said: “Patients with conditions such as strokes, fits and cardiac arrest need to be treated very quickly. As Monitor has accepted, a 27 minute delay for one man waiting for an ambulance caused his death.

“We regularly act for patients who have suffered as a result of a delay in receiving treatment. In this instance, the trust's rogue scheme may have contributed to a worse outcome for many patients. If there was a delay in you receiving an ambulance between December 2014 and February 2015, we encourage you to get in touch."