36.6% of the target patient group. falls: a paramedic with additional training and equipment paired with an assistant to appropriately assess elderly fallers in a timely manner, treat as required and be able to make additional referrals to ensure patients are supported at home. mental health: ensuring that a suitable mental health clinician is available to patients 24/7 by having registered mental health nurses (rmn) available in the clinical hub, as well as introducing vehicles with a rmn paired with a paramedic to provide appropriate assessment and treatment for people experiencing a mental health crisis. this includes transport to more appropriate facilities than an emergency department where possible. maternity: an ambulance rapid response vehicle with a registered midwife and paramedic with an increased ability to assess and treat on scene, as well as increased access to community services enabling mothers to stay at home where possible. end of life: las will invest in knowledge and skills involving these patients, developing stronger links with hospices and review the pharmacology available to the crews to make this stage of life as comfortable and dignified as possible. volunteers volunteers make up a small but significant proportion of front line ambulance staff that respond to emergency calls in london. voluntary responders vary in skill level, but their principal purpose remains the same. that is to attend medical emergencies as quickly as possible to improve the patient's chance of survival, saving lives which may have been lost without the additional resources being available to the ambulance service. importantly, the deployment of any voluntary responder will not replace the automatic allocation of a regular front line ambulance. there are two principal roles for volunteers within the london ambulance service. these roles include: emergency responder - clinically trained volunteers who operate in marked response cars with blue lights and wear full service uniform, typically working double-crewed and doing shifts of up to ten hours day and night. these come from public-sector backgrounds, including policing. community responder - defibrillator trained st john ambulance volunteers attending on call from their homes and responding to 999 calls in their own car without blue lights alongside ambulances. las volunteers are supported by london ambulance service voluntary responder group, providing logistical and financial assistance to keep volunteers operational. las can also call upon auxiliary aid from external voluntary organisations such as st john ambulance and the british red cross, as demonstrated in the 7 july 2005 london bombings. las also utilises the goodsam app to alert off duty trained medical persons to a nearby cardiac arrest and the location of nearby automated external defibrillators. fleet a mercedes-benz sprinter ambulance a fast response unit a response motorcycle an las rapid-response bicycle the las operates around 450 emergency ambulances. in addition it can deploy around 100 fast response units in various cars, motorcycles, or bicycles. although not a part of the las, london's air ambulance charity is deployed by the las from its base at the royal london hospital in whitechapel using either its ground rrvs or its helicopter. as well as accidents and emergencies, the las operates a 195-vehicle patient transport service (pts). previously a centrally funded service, this element of the las is now subject to an open market and is required to tender for work from primary care trusts (pcts) and other nhs bodies. as well as being contracted by a number of london hospitals and pcts to take patients to and from their pre-arranged hospital or clinic appointments, the pts responds to ad hoc journey requests and provides specialist transfer facilities. cycle responders, who operate in areas such as the city of london, the west end, stratford, kingston town centre as well as heathrow airport, use custom built rockhopper mountain bikes manufactured by specialized bicycle components. in 2017, 140 new mercedes sprinter ambulances were introduced and 60 new volkswagen tiguan to be incorporated into the fast response unit fleet. notable incidents the las plays a significant role whenever an incident causes mass casualties in london. examples include: provisional ira bombing campaign: 1969–1997, a list of these and other bombings in london to which the las responded can be found here. moorgate tube crash: 28 february 1975, the train driver and 42 passengers were killed king's cross fire: 18 november 1987, 31 people died in a major fire in the underground station clapham junction train crash: 12 december 1988 35 people were killed and 69 seriously injured marchioness disaster: 20 august 1989, a pleasure boat, marchioness, was in collision with a dredger; 51 people died cannon street rail crash: 8 january 1991, two people were killed and over 500 injured southall rail crash: 19 september 1997, an intercity 125 collided with a freight train on the great western main line resulting in 7 deaths and 139 injured persons. paddington train crash: 5 october 1999, two trains collided a short distance outside of paddington station, resulting in the deaths of 31 and 523 persons injured 7 july 2005 suicide attacks: four simultaneous suicide bombings across london resulting in 56 deaths (including 4 assailants) and at least 700 persons injured. voluntary aid services needed to assist the las due to scale of the attacks. 2012 summer olympics croydon tram derailment: 9 november 2016, a tram derailed in south london resulting in 7 deaths and 62 persons injured westminster attack: 22 march 2017, a vehicular ramming and knife attack resulting in 6 deaths (including the assailant) and 49 persons injured london bridge attack: 3 june 2017, a vehicular ramming and knife attack resulting in 11 deaths (including 3 assailants) and 48 persons injured grenfell tower fire: 14 june 2017 in kensington, causing 72 deaths and over 70 injuries. parsons green bombing: 15 september 2017, a non-fatal bombing of a london underground train resulting in 30 injured persons. contracting services due to an increase in demand, the las has used private ambulance companies, and some charities, to provide additional everyday operational cover. this is largely to ensure set response targets are met and so that the level of resources available to the service stays at a safe level. the future of private ambulances within the las is unclear. in march 2014, operational difficulties were reported at hillingdon hospital because the private ambulances did not appear on the a&e hospital alert system. as of 2022, las contracts out to two private company, emfs group and polaris medical who both provide bariatric services as well as a small number of ambulances. las also deploys st john ambulance mutual aid crews to a limited range of low acuity calls. in november 2021 the trust announced that it would be directly employing the 500 staff in "make ready" teams who are responsible for cleaning and restocking ambulances before they are taken out. they have been employed by mitie for some years. cqc performance rating in its last inspection of the service in september 2019, the care quality commission (cqc) gave the following ratings on a scale of outstanding (the service is performing exceptionally well), good (the service is performing well and meeting our expectations), requires improvement (the service isn't performing as well as it should) and inadequate (the service is performing badly): inspection reports area rating 2015 rating 2017 rating 2018 rating 2019 rating 2020 are services safe?inadequaterequires improvementgoodrequires improvementrequires improvement are services effective?requires improvementgoodgoodgoodgood are services caringgoodoutstandingoutstandinggoodgood are services responsiverequires improvementgoodgoodgoodgood are services well-ledinadequaterequires improvementgoodgoodgood overall ratinginadequaterequires improvementgoodgoodgood difficulties and criticisms in 2000, the las faced funding difficulties and an increase in the volume of 999 calls, and it was criticised for poor performance in its response times. the service was sued for negligence in the case of kent v griffiths. the chief executive at the time, michael honey, left his post after talks with other members of las management. in 2010, the service lost its funding for the emergency care practitioner (ecp) role and existing ecps were told they must change to a different role within the service, or leave. a fire in the basement of its waterloo base in october 2010 caused the las to relocate the eoc to the back-up control room in east london due to an interruption to the building's power supply. the service took the step of urging the public to find other means of transport to hospital for anyone with non-life-threatening injuries. in 2013, the las was named by the care quality commission as one of 26 healthcare providers in england failing to operate with sufficient staff. in september 2014, the trust announced that it would reduce the number of category c calls (the least serious) which receive an ambulance response by 15%. these calls will be triaged by a call handler and either referred to nhs 111 or given telephone advice by a paramedic. in 2014 only 64% of category a patients were reached within eight minutes and it is hoped that by this measure there will be an improved response to the most urgent calls. it has also implemented a system of "intelligent conveyancing" where ambulances avoiding hospitals that are known to be under pressure. this has reduced the average waiting time for handover from ambulance to hospital staff by 180 seconds, though the average journey time has increased by 27 seconds. in december 2014, it asked other ambulance services for help after its busiest ever week with 11,008 call outs for the most seriously ill and injured. demand is up 15% on the same time last year. help has only been requested previously in respect of events like the olympics or the 2005 bombings. the service has more than 400 vacancies and has had problems recruiting people. it is failing to reach its response targets. in 2014/15, the trust recruited 175 paramedics from australia. the trust was placed into special measures following a report by the care quality commission (cqc) in november 2015, which rated it "inadequate" overall and raised "significant concerns" about its performance. 54 inspectors visited 16 ambulance stations and emergency operation centres in june. criticisms focussed on: a "culture of harassment and bullying" and a perception that "discrimination" was not dealt with. verbal and physical abuse, ostracisation, sexual harassment, misuse of power and cyber-bullying had been featured in an earlier independent report long working hours, with high levels of stress and fatigue reported by a large number of "demoralised" frontline staff response times which had deteriorated since march 2014 with a consistent failure to meet the national benchmark of 75% of patients with life-threatening conditions receiving treatment within eight minutes many frontline vacancies, and insufficient appropriately trained paramedics to ensure patients were consistently safe and received good care lack of necessary equipment insufficient understanding of the challenges staff experienced by senior managers and board members insufficient supervision for newly qualified paramedics from senior colleagues failure to review major incident procedures, which are supposed to be reviewed annually, or to ensure all staff were aware of them on 23 may 2018, las was taken out of special measures by the cqc, being rated good overall and outstanding in patient care. the report noted that the trust needed to focus on ensuring safe staffing levels of the control room, diversity amongst staff and improvements in management of mental health. 7/7 bombings ambulances in attendance at russell square on 7 july 2005 concerns were raised in internal las documents over the performance of radios and communication equipment used in the emergency operations after the 7/7 attacks. again, the sheer volume of emergency calls received made radio communications difficult and put pressure on staff in the ambulance control room. staff were also hampered in their use of mobile phones as the mobile phone networks were temporarily brought down during the day. in july 2009, the new radio system recommended after the bombings was rolled out. despite the changes after 7/7, the las was criticised in 2010 for failures to provide fully working radios to its frontline staff. health and safety inspections found that some radios failed during heavy rain and staff sometimes had to do without. crews also raised concerns that the panic buttons on their radios did not work properly. innovation in 1974, the las commissioned a computer-aided despatch system that remained unused for 13 years because union members refused to operate it. a replacement system failed acceptance tests in 1990 and a further replacement system