The Care Quality Commission (CQC) was aware of a key report highlighting concerns about how North East Ambulance Service was withholding information with coroners as long ago as June 2020.
But at that time, following contact with stakeholders, the regulator decided "further, immediate regulatory action was not required at the time".
Whistleblowers contacted the health regulator in May that year, and shortly afterwards the CQC requested information including the damning independent AuditOne report into the service's timeliness at ensuring coroners around the region were aware of "concerns and / or investigations" into patient safety incidents.
Information obtained under Freedom of Information rules confirmed that NEAS shared the report with the CQC in summer 2020. But after contacting stakeholders including coroners, the regulator felt there was not then the need to take further action. Further whistleblowing in 2021 and 2022 was taken into account in a damning inspection report published this year.
Whistleblower Paul Calvert, who worked in the NEAS coroners and claims team, said he felt "the regulators were in possession of damning information almost three years ago but that they failed to act upon the damning evidence in the Audit One report".
When Paul went public with concerns that he and others had previously raised privately and with agencies such as the CQC, NEAS admitted there had been "historical failings" in its approach to sharing information with coroners. However, the ambulance service has continually maintained this has not continued.
The report from AuditOne - an external firm specialising in investigating NHS conduct and counter-fraud - highlighted how one investigation report shared with a coroner was altered and in "direct contrast" to what had initially been written.
In July and September last year, the CQC inspected services at NEAS - and in a report published in February 2023 rated the ambulance service as "requires improvement". The report also touched specifically on how NEAS dealt with whistleblowers - warning inspectors were not convinced by its response to long-running whistleblowing concerns.
Whistleblowers including Paul had raised concerns about disclosures to coroners in cases where internal investigations had taken place. These included investigations into circumstances around the deaths of Quinn-Evie Milburn Beadle and Peter Coates. In Quinn Evie's case, paramedics arriving on the scene raised concerns about the actions of one of their colleagues - Gavin Wood - who had been the first paramedic to attend to Quinn Evie.
Earlier this year, Mr Wood was struck off by the Health and Care Practitioners Tribunal Service (HCPTS) over his conduct in Quinn Evie's case and his failure to provide advanced life support. However, at the time of the first inquest into Quinn Evie's death, the fact that an internal investigation took place into Mr Wood's actions was not initially disclosed to the Quinn Evie's family and only came to light part-way through the inquest.
Quinn Evie's parents last month told ChronicleLive how they were frustrated by delays to the publication of a review commissioned by NHS England into NEAS' handling of her case and others also highlighted in the AuditOne report. It was initially expected in the early part of the year.
Commenting on the CQC's actions when receiving concerns from whistleblowers, a spokesperson for the agency said: "CQC was contacted by whistleblowers in May 2020. They raised concerns about the coronial process in NEAS (North East Ambulance Service NHS Foundation Trust).
"We reviewed the concerns and asked NEAS to provide a range of information that included, but was significantly wider than, the Audit One report. We also spoke to other key stakeholders including the coroner. We decided that further, immediate regulatory action was not required at the time. The concerns and information received from NEAS were retained.
"Following further whistleblowing concerns in 2021 we asked for additional updates and information from NEAS which showed that actions were still in progress. In June 2022 we found that NEAS had still not delivered all of the actions to ensure that the systems and processes were embedded and were consistently operating effectively.
"We inspected NEAS in July and September 2022 and took action requiring them to make further improvements. The report of that inspection is on the CQC website https://www.cqc.org.uk/provider/RX6."
NEAS maintains it has addressed the historic issues raised by whistleblowers. Its chief executive Helen Ray has said the service co-operated with the "independent review" - led by Dame Marianne Griffiths - and while that review's publication is pending the service has not commented in further detail on the issue.
In response to being branded "requires improvement" by the CQC, a spokesperson said: "Providing the best possible care to all our patients remains our top priority. We are all committed to making improvements until we and the CQC are confident that the concerns raised have been fully addressed
"In the six months since the first inspection, we have taken swift action and subsequently provided additional assurance to the CQC that the work will ensure effective systems are in place to keep patients safe. We recognise there is more to do and are committed to longer term change as well as a short-term response."
A spokesperson added: "We have a workforce of more than 3,500 people and were disappointed that some staff in a CQC survey of 430 respondents said they felt they could not raise their concerns. We actively encourage our staff to raise concerns in the confidence they will be dealt with quickly and effectively."
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