Ambulance workers in the north-east of England have rejected a deal which would have ended a long-running dispute over meal-breaks.
The North East Ambulance Service NHS Trust had offered workers an annual payment of £1,500 to respond to emergency calls during their breaks.
Members of the trade union Unison voted on Thursday night two to one against.
The trust said it was disappointed by the decision and will be holding further talks with Unison on Friday.
Since June, North East Ambulance Service paramedics have received unpaid and undisturbed meal breaks.
They said that as a result there had been a number of incidents where crews nearest an emergency had not been contacted but crews had been forced to attend from further away.
Unions said staff wanted to be paid for meal breaks and being on standby.
Dave Armstrong, Unison regional officer, said following the ballot result: "Our members obviously feel that the trust's offer is an inadequate measure in providing a full emergency ambulance service to the people of the region."
Simon Featherstone, Chief Executive of the North-East Ambulance Service, said: "I am bitterly disappointed at this result.
"We feel this is a generous offer which is comparable with what I have seen made by other ambulance service trusts in the UK."