The Portugal Public Prosecutor's Office has officially closed all six criminal investigations into deaths that occurred during the October-November 2024 strike by emergency medical technicians, citing an absence of definitive evidence linking delays to fatalities. Yet the announcement, made public this week, has collided with a deeper controversy: a proposed overhaul of the National Institute of Medical Emergency (INEM) that four former agency presidents now warn could fragment the very system those deaths exposed as fragile.
Why This Matters:
• All 6 criminal inquiries closed despite health inspectors linking 3 deaths to delayed rescue.
• INEM's new legal framework transfers ambulances to hospital units and downgrades advanced life-support vehicles—criticized as "dismantling" by former leaders.
• Parliamentary inquiry suspended until June after allegations of "silent strike" instructions emerge via WhatsApp evidence.
• Disciplinary case open after a 48-year-old man in Santarém waited 50 minutes for an ambulance and died last weekend.
The Prosecutor's Verdict: Probable, Not Provable
Between October 30 and November 4, 2024, a labour dispute among Portugal's pre-hospital emergency technicians paralyzed response capacity across the nation. Twelve people died during the strike window. The General Inspectorate of Health Activities (IGAS) completed its investigation in September 2025 and flagged three fatalities as potentially preventable with immediate intervention: an 86-year-old cardiac arrest victim in Bragança, a 53-year-old man in Pombal, and an 84-year-old choking victim in Mogadouro.
The Bragança Public Prosecutor, in a decision dated October 30, 2025, acknowledged a 48-minute gap between the first 112 emergency call and the dispatch of rescue units. But the case was shelved based on a technical opinion from the National Institute of Legal Medicine, which concluded that "the outcome would very probably have been identical had the event occurred in a hospital with all rescue means immediately available." The 86-year-old patient had multiple comorbidities and suffered a myocardial infarction at home—circumstances that, prosecutors argued, would likely have defeated even optimal care.
Similar reasoning underpinned the closure of the Mogadouro and Pombal files. In each instance, prosecutors noted the absence of a secure causal nexus between the dispatch delay and death, despite the health inspectorate's assertion that swifter action could have changed outcomes. The legal standard—proof beyond reasonable doubt—was not met.
A System Under Reconstruction—or Deconstruction?
On May 7, the Portugal Cabinet approved a new Organic Law for INEM, elevating the agency to Special Regime Public Institute status. Health Minister Ana Paula Martins defended the reform as necessary to introduce "strong clinical governance" and operational flexibility, including better pay scales and professional recruitment. The blueprint includes:
• Transfer of INEM's own ambulances to Local Health Units (ULS), refocusing those vehicles on inter-hospital patient transfers rather than primary emergency response.
• Conversion of Immediate Life Support (SIV) ambulances into lightweight passenger vehicles.
• Return of Medical Emergency and Resuscitation Vehicles (VMER) to inter-hospital transport duty.
• Concentration of basic rescue with volunteer fire brigades and the Portuguese Red Cross.
• Introduction of artificial intelligence tools in the Urgent Patient Guidance Centers (CODU).
• Removal of the requirement that the president of the Board of Directors be a physician, replaced by a structure mirroring hospital units: a clinical director and a nursing director.
Former Leaders Sound the Alarm
Four former INEM presidents—Sérgio Janeiro, Luís Meira, Regina Pimentel, and Miguel Oliveira—alongside ex-head of the Emergency Medicine Competence College Vítor Almeida, published an open letter in Expresso on May 15 expressing "deep concerns" and "technical and operational reservations."
Their core argument: the measures risk fragmenting the Integrated Medical Emergency System (SIEM), compromising national coordination capacity and integrated response during catastrophes. They warned that diverting VMER units to hospital transfers will weaken primary rescue, while converting SIV ambulances into cars undermines advanced pre-hospital care. Shifting INEM's ambulances to hospital units, they contend, will prioritize patient shuffling over life-or-death intervention.
The former leaders advocate modernizing and reinforcing the existing system rather than dispersing resources. They propose creating a dedicated inter-hospital transport network for hospital units, freeing INEM to focus on its original mission, and granting the institute greater management flexibility to simplify hiring and procurement.
The INEM Workers' Commission echoed the criticism on May 10, calling the reform a "dismantling of what should be reinforced" and rejecting the hospital-unit integration model.
What This Means for Residents
For anyone living in Portugal, the reforms and unresolved questions about the 2024 strike deaths translate into uncertainty about emergency response reliability. The legal closure of the criminal files does not erase the operational failures documented during the strike—nor does it resolve the structural deficits that existed before October 2024.
Practical concerns include:
• Response time variability: The current model sets priority levels with response windows from 8 minutes (emergent) to 120 minutes (low urgency). Transferring INEM ambulances to hospital units may lengthen those windows if resources are diverted to non-emergency transfers.
• Geographic inequality: Interior regions already face longer waits than coastal urban centers. Fragmenting the system risks deepening that gap.
• Professionalization bottleneck: Portugal faces an estimated shortage of 14,000 nurses in the National Health Service (SNS), directly affecting pre-hospital care. The reform's emphasis on clinical governance will mean little without addressing the manpower crisis.
• Private sector role: Recent government measures allow private ambulances without sirens to handle less severe cases—a move the Portuguese Society of Pre-Hospital Emergency (SPEPH) warns could represent a "significant setback" in clinical assistance if not grounded in robust technical criteria.
European benchmarks show that many countries—Sweden, Finland, Belgium, England, Wales, Spain, and the Netherlands—integrate nurses and paramedics with advanced life-support training into pre-hospital services. Portugal's reliance on volunteer fire brigades for 95% of basic rescue, while cost-effective, limits the scope for rapid professionalization.
The Parliamentary Inquiry: Suspended, but Loaded
The Parliamentary Commission of Inquiry (CPI) into INEM, approved in July 2025, is tasked with identifying political, technical, and financial accountability. Composed of 24 deputies, it aims to deliver findings by approximately July 25, 2026. But in mid-May, the commission suspended hearings until June to await missing documentation.
Before the pause, the inquiry had already generated revelations. The Liberal Initiative party secured unanimous approval for a hearing with Miguel Ângelo Santos, former coordinator of INEM's North regional delegation, who claims to possess documentary evidence—including WhatsApp screenshots—of alleged instructions for a "silent strike" that complicated staff scheduling in October 2024. The commission also voted to preserve all metadata related to the strike notice email dated October 10, 2024.
Liberal deputy Mário Amorim Lopes argued Santos must confirm the "threat" in person. The inquiry also approved, with abstention from the Social Democratic Party (PSD), a hearing with Jorge Salgueiro Mendes, former chief of staff to Health Minister Martins.
Former INEM president Sérgio Dias Janeiro, who was recalled for questioning in April 2026 after contradictions emerged about his knowledge of strike warnings, had testified that INEM faced a structural human resources deficit that prevented mobilizing non-existent professionals and legally constrained overtime limits.
The Santarém Case: A System Still Breaking
The reform debate unfolded against the backdrop of a fresh tragedy. On May 11, José Luís, a 48-year-old epilepsy patient in Ourém (Santarém district), waited nearly 50 minutes for an ambulance after his father called 112 at 5:54 PM. A cascade of errors followed: the Santarém Volunteer Firefighters were dispatched 11 minutes later to the wrong address—despite there being only one hamlet called "Moita do Lobo" in the municipality. The correct location, 9 kilometers away, was confirmed at 6:13 PM. By 6:16 PM, the patient was in cardiorespiratory arrest.
Firefighters requested a VMER unit immediately, but Santarém's VMER was inoperational and Caldas da Rainha's was occupied. The responding ambulance lacked an external automatic defibrillator because the priority level had been upgraded mid-route. Firefighters arrived around 6:44 PM—50 minutes after the initial call. José Luís was transported to hospital but died shortly after.
The INEM Board of Directors announced on May 15 the opening of a disciplinary proceeding against the CODU technician involved, alongside an investigative process to audit the entire operational response, including decision circuits and inter-agency coordination. The institute expressed condolences to the family.
Germano da Silva, the victim's father, told CNN Portugal his son had dismissed the initial dizziness as "nothing." The firefighters' commander, Rui Carvalho, described the incorrect address as a rural location with difficult road access, compounding the delay.
The Bigger Picture: Accountability Without Clarity
The closure of the criminal inquiries may satisfy legal standards, but it leaves a political and operational vacuum. The IGAS findings—that three deaths were linked to delays—remain unchallenged, even as prosecutors concluded the causal link was unprovable in court. The gap between administrative blame and criminal liability has become a flashpoint in the parliamentary inquiry.
Meanwhile, the structural overhaul moves forward, backed by the government's promise of modernization but opposed by those who built the system. The tension is between clinical governance and operational capacity—between a hospital-integrated model that prioritizes seamless patient flow and a dedicated emergency institute that owns its response chain from call to care.
The debate will resume in June when the CPI reconvenes, armed with the documentation it awaits and the testimony of insiders who claim to have evidence of internal sabotage. For residents, the stakes are immediate: whether the next 112 call will be answered in 8 minutes or 50, and whether the ambulance that arrives will carry the tools and training to save a life.
Portugal's emergency medical system was once considered a "collective heritage" recognized internationally. The question now is whether the reforms will restore that reputation—or accelerate its unraveling.
