REGULATION 28: REPORT TO PREVENT FUTURE DEATHS RESPONSE OF MAGENTA LIVING TO CONCERNS OUTLINED PURSUANT TO REGULATION 28; REPORT TO PREVENT FURTHER DEATHS _ MR:VOLANTE In the case of Mr Ronald Volante Background Magenta Living delivers a Community Alarm monitoring service to our own tenants and as in the case of Mr. Volante;, to other local housing associations that do not provide their own monitoring services directly: The service Is a non-statutory housing related service aimed at promoting independent within a home setting: It is accredited by the TSA (Telecare Services Association) which is the national body against whose standards we are assessed, Magenta Living does not provide a visiting warden'$ service to this scheme. CORONER'S CONCERNS Magenta Support Link had access to Mr. Volante's medical history and there is no evidence that this was used to advise the ambulance servlce of his cardiac problems is this covered in the induction training of call handlers Current practice Hitherto the approach has been that once through to the Ambulance Control Centre the community alarm operator is taken through a set of standard questions by the Ambulance Service operator These questions are designed to elicit sufficient information in respect of the address, location, access arrangements and the condition ofthe person concerned and is used by the Ambulance Service to prioritise calls This is reflected in Magenta Living'$ written procedure, which is provided to all call handlers as part of their training, which states in relation to "Requesting ambulance attendance" , that "if requested by the ambulance service controller , the call handler shall provide such additional information as they have in respect of the incident and the building: Proactively providing medical history to the ambulance service at the point of initial contact by call handlers was not covered in induction training for call handlers. This does not form part of the procedure accredited by the TSA procedure was established in the context that the ambulance service Is in a better position to assess what information is and isn't relevant In Mr Volante's case, the Magenta Living call handler followed procedure and answered the questions posed to him by the ambulance service controller and no details regarding medical history were requested: Had the ambulance service controller requested such detail, they were In the position to assess whether medical history was relevant, our call handler would have provided the information Response to Coroner' $ concerns Following the concerns raised at the inquest and subsequently detailed in the Regulation 28 Report to Prevent Further Deaths Notice we have revised how we will deal with calls to the Ambulance service. We have written to all ofour community alarm customers, including those organisations with whom we have contracts to provide a similar service. We have confirmed that with immediate effect that there will be an addition to current procedures in living Living The and

so far a5 we will share medical details at the point of contact with the emergency services unless service users specifically advise us otherwise As a result of this change of procedure, all Magenta Living community alarmed trained call handlers were briefed with effect from 28th January 2016 as to this change and provided with a copv of the updated procedure that now includes this additional stage. As part of this discussion, staff confirmed their understanding of the new procedure which Is recorded in their training record: This of procedure will also be addressed with new staff as part of their normal induction programme_ Additionally, a5 part of our commitment to improve service standards, we have liaised directly with the TSA and discussed in detail the concerns raised by the Coroner: Whilst the TSA reaffirmed that there is currently no national requirement to share medical information with the emergency services, the TSA has confirmed their intention to review the relevant parts of their Code of Practice. The TSA has indicated that they aim to introduce measures to ensure that the provision of medical history to the ambulance service is embedded within the Standards Framework within the Code of Practice as national practice in the future; Upon receipt of the amended Standards Framework from the TSA, we will provide a copy to the Coroner Magenta Living Support Link were aware that there had been a change in Mr. Volante's presentation by 18,46 as he did not respond to the news that an ambulance was on the way - is this covered in induction training of call handlers with regard to advising a doctor or emergency service of a change in circumstances after the first call Current practice Historically, a change of circumstances would not result in a call handler updating the emergency services To provide context this Is because of the way the contact centre is connected to the sheltered housing scheme: The contact centre is connected to each scheme via a telephone line which allows the call handler the ability to speak with a resident who has activated the alarm as well as being able to control the communal door entry system to the block of flats When an alarm is activated by a resident, the call would be closed down once the next of kin or ambulance service had been notified and as such a change of circumstance would not necessarily be evident: This practice was adopted due to the fact that keeping the line open could potentiallv impact upon our ability to respond to further activations from residents at the same scheme and to provide remote access to the emergency services when they arrive through the communal door entry system. Response to Coroner'$ concerns In light of the Coroner'$ concerns, all Magenta Living'$ community alarm call handlers have been briefed with effect from 28th January 2016 that they should update the emergency services of any change in the client'$ circumstances presentation as soon as these are known; To achieve this and to take into account the resource pressure experienced by the North West Ambulance Service and the Impact upon their response times, we have now adopted a policy whereby a call handler will maintaln regular contact with the resident until their key holders (next of kin) or emergency services arrive. This change of practice has been updated in our revised procedure: It is hoped that this approach will provide support change any

to the North West Ambulance Service and assurance to those affected by delays in respect of ambulance response times: As detailed above; all Magenta Living community alarmed trained call handlers have been briefed in respect of this change and provided with a copy of the procedure that now includes these additional stages. As part of the discussion, staff confirmed their understanding of the new procedure which Is recorded in their training record. This change of procedure will also be addressed with any new staff a5 part of their normal induction programme: The training manual and method of training call handlers needs to be revisited in light of the experience from Mr. Volante'$ tragic death Current practice Magenta Living's has a thorough, comprehensive training and induction programme which is accredited by the TSA. Individual performance is regularlv monitored through work reviews, team meetings, auditing and quality assurance, coaching; external auditing (for accreditation purposes), contract monitoring and customer feedback; Response to Coroner'$ concerns However, in light of the Coroner'$ concerns and appreciating that standards can always be improved, Magenta Living has incorporated a number of additions to the procedures manual as a result of the Coroner's recommendations as set out above: Our standard practice, which has been followed in respect of these changes, is that ay changes or amendments made to procedures are always quickly communicated to staff across the various shifts. This is carried out on a one-to-one basis ad also at team level. For assurance purposes, Team Leaders and managers ensure staff implement any changes smoothly ad effectively and measures are put in place to monitor this such as spot auditing listening to call recordings, data checks_ concerns are immediately brought to the attention of the member of staff and a performance improvement plan is established; This may include for example further coaching, side by side monitoring and peer support until an acceptable performance level is attained: As a learning organisation, training for Magenta community alarm handlers is continuous and this approach will continue DATED 23 MARCH 2016 Any Llving