The report said the LAS management 'created an atmosphere of mistrust' with its over-aggressive style, born in part out of desperation to put right decades of poor performance.
The LAS made 'virtually every mistake in the book', when implementing its 'ambitious' pounds 1.5m computer system, one of the three-strong inquiry team said. This computer-aided dispatch (CAD) system was seen as the only hope the service had to put right its poor response times in dealing with emergency calls. But the software was 'not complete, not properly tuned, and not fully tested', the report said.
The inquiry team was set up after the CAD system broke down on 26 and 27 October last year, then collapsed a second time on 4 November, forcing controllers to revert to pen and paper to dispatch ambulances.
Managers took a high-risk, 'misguided' decision to have the CAD system up and running in one phase. The system was developed and installed in 'an impossible timetable', the report said. The final system had known technical problems, and the people who would have to use it were not properly trained to do so. The team concluded that LAS management ignored advice to this effect 'from many outside sources'.
One of the team members, Paul Williams, said management had concentrated on getting the best price for its computer system, rather than the one which would be best for the job.
He said he would have expected a system of this kind to have cost at least twice as much as the LAS computer. The report said there was 'no evidence of key questions being asked about why the (final) bid was substantially lower than other bidders'. The report questioned the apparent lack of accountability within the service itself, and upwards to managers at regional level. This was exacerbated by LAS operating at arm's length from its health authority, which meant it was not subject to checks from regional managers.
The team said that although the computer system did what it was supposed to do, the design had 'fatal flaws' that together would lead to all the symptoms of a systems failure. It found that System Options, the software company which supplied the system, had never before dealt with a system this large and complex. 'We believe they (the software supplier) rapidly found themselves in a situation where they were out of their depth.'
The team believes some parts of the failed computer system can be salvaged, although chunks of the applications software may need to be substantially re-written.
The report refutes earlier statements from the LAS that the two disastrous days in October had been exceptionally busy. The number of calls was in fact only a little above average. It was only when ambulances failed to arrive, and duplicate calls came in, that things got out of hand.
LAS board members appeared to have been given a 'misleading impression' about progress with the computer system, and regional managers seemed to have even less of an idea of what was going on within LAS.
Last year's crisis prompted the resignation of John Wilby, then chief executive of the service. Yesterday, South West Thames Regional Health Authority revealed that it had already decided to remove Mr Wilby from his post, having first raised fears over his performance at a meeting with him six months before the computer breakdown.
Jim Harris, LAS chairman, denied that this might have put pressure on Mr Wilby to produce results. But the report concluded that 'an important factor was almost certainly the culture within the LAS of 'fear of failure'.'
Professor Marion Hicks, the health authority's chairman, said Mr Wilby was given a limited length of time to improve, but by mid-October 'the decision had been taken to terminate his contract'. This would have gone ahead in November if the LAS board had not been taken over by events, and Mr Wilby's voluntary resignation.
Non executive LAS board members who remain are: Roddy Braithwaite, Victor Paige, Mary Spinks, Janet Preston and Stephen Miles. The executive comprises: Martin Gorham (chief executive), Alan Kennedy (acting director of operations), Simon Young (director of Finance), and Bernadette el-Hadidy (director of human resources).