Dear Mr Landau Regulation 28 Report – Mr Richard Boateng I write on behalf of the College of Policing (the College) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, prevention of future death report to the College dated the 26th February 2021. The report sets out concerns that arose from the information received during the inquest in to the death of Mr Richard Boateng. I was very sorry to read of the circumstances of Richard’s death. My sympathies are with his family and friends and I share your commitment to addressing the issues that contributed to his untimely loss. The report sets out your principle considerations in respect of the current guidance provided to forces in respect of the conveyance of patients to hospital in an emergency if no ambulances are available. More specifically your letter provides the following information. College of Policing - Due to the Covid pandemic, no ambulances were available when police attended to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in an emergency if no ambulances were available. However, the policy included no practical guidance as to how that could be achieved mitigating the risks. I heard that the Metropolitan Police Service is updating the guidance. However, I am concerned that other forces across the country may also lack such practical guidance, which is of particular concern due to ongoing pandemic and the demands that may continue of ambulance services The College is the independent professional body supporting everyone working in policing to reduce crime and keep people safe. The College has three complimentary functions;
• Sharing knowledge and good practice: creating and maintaining easy access to knowledge, disseminating good practice, and facilitating the sharing of what works

• Setting standards: setting standards for key areas of policing which help forces and individuals provide consistency and better service for the public

• Supporting professional development: setting requirements, accrediting, quality assuring and delivering learning and professional development, promoting diversity and wellbeing, and helping to nurture and select leaders at all levels. The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including the Metropolitan Police Service. The programme is endorsed by the National Police Chiefs’ Council (NPCC) and the Health and Safety Executive (HSE). The College is responsible for ensuring appropriate quality assurance processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision of first aid. However, transportation of casualties to hospital are not within the scope of the responsibility of a first aider (and therefore the FALP). The transportation of casualties in police vehicles carries inherent risks to the casualty, requiring skills and responsibilities significantly above those of a first aider, and significant liabilities to the officers themselves. For these reasons instances of police transporting casualties should be kept to the absolute minimum and there is concern that development of College issued guidance would not only ‘normalise’ such practices but add to an unrealistic expectation being placed on officers at the scene. That said, there will be instances when this may be necessary, and in those scenarios I would expect officers to conduct a dynamic risk assessment at the scene. The College has developed Authorised Professional Practice (APP) to aid decision making National Decision Model (college.police.uk); this practical guidance guides officers through a process of considering the information, assessing the risks, considering policy and available powers, identifying options and finally taking action. In the absence of an ambulance and taking account of the prevailing circumstances (in particular the risk to the patient), I consider that the APP already provides appropriate guidance. In considering the response, my team has also liaised with the NPCC portfolio leads for Response Policing (Chief Constable ) and Health and Safety (Asst. Chief Constable

). Both are in agreement with my response, and I understand that Chief Constable is going to discuss the issue of the availability of ambulances with her NPCC colleagues to explore the national context. As a matter of course, all coroner reports and inquests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. My staff have spoken with the forum chair and have agreed to escalate this issue to the Forum for consideration as to what practical advice can be offered to forces. The College is committed to continuing our work with forces, the NPCC and other agencies to raise standards of practice in the care of people who come to police attention. We would like to thank you for bringing the circumstances of Mr Boateng’s death to our attention so that we can ensure that our immediate and future work is informed by the events that culminated in his death.

Dear Sir Regulation 28 Prevention of Future Deaths Report, arising from the inquest in to the death of Mr. Richard Boateng Thank you for your Regulation 28 PFD Report dated 24th September 2021, setting out your concerns to be addressed. I would like to begin by expressing London Ambulance Service NHS Trust’s sincere condolences to Mr. Boateng’s family. The issue you have asked LAS to consider in the PFD report is as follows: The GP called LAS concerned about Richard’s welfare. LAS attended his home address. Richard was not there. The LAS paramedic advised his sister to call the police. The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact. I was told that national guidance on this issue was published in the summer. To date, neither guidance to crews nor to control had been updated to make the LAS guidance clearer to those applying it. Legal Services Headquarters 220 Waterloo Road London SE1 8SD

I set out below the actions that have been, and continue to be, taken in relation to our policies and procedures and staff awareness, in light of this case.

Immediate Action Taken: Staff Bulletins

We gave evidence at the inquest confirming that the relevant LAS policies dealing with ‘no trace’ calls are OP14 (Managing the Conveyance of Patients – for frontline staff) and and OP23 (Dispatch of Resources – for control room emergency operations centre, ‘EOC’ staff). Those polices are being updated, and I give further information below about this.

Pending finalisation of the updates to those policies we have developed bulletins for the above cohorts of staff, which have been issued.

The frontline staff bulletin details the actions to be taken when a patient cannot be located, namely:  conducting a thorough area search;  contacting EOC to confirm the address;  requesting that EOC check with local hospitals if there is a concern that the patient is at risk from an illness or injury (physical or mental health);  contacting EOC to request the assistance of the Metropolitan Police, if the above actions have not been fruitful in locating the patient, and if there continues to be a concern that the patient is at risk from an illness or injury (physical or mental health). The bulletin emphasises that the request for the police must be made by the LAS on scene, via EOC, and must not be left to members of the public to undertake.

These actions must be documented on the call log (‘CAD’) by EOC and on the patient record (’ePCR’) by frontline staff.

The EOC staff bulletin corresponds with the above. It makes it mandatory where there is a concern for risk, or where the patient is deemed to be vulnerable, that EOC contact the police and provide all available information. It also states that this must not be left to member of the public or staff from other agencies to undertake, and should be made via EOC.

Both bulletins also clarify that the police will accept a missing report of a vulnerable (at risk) person immediately.

Each bulletin provides non-exhaustive, detailed guidance as to types of vulnerable patients.

The bulletins have been sent out by our communications team and added to the LAS intranet, ‘The Pulse’. Awareness will be reinforced when they are covered on our regular intranet ‘LAS TV Live’ session on 17th November 2021, and in our Routine Information Bulletin, ‘The RIB’, on 16th November 2021. In addition, they will be communicated to all staff via the weekly ‘LAS Roundup’ email on Friday 19th November 2021.

LAS has established processes for sharing updated guidance and information digitally with staff via personally issued i-pads and the frontline bulletin has been disseminated to the ‘JRCALC+’ app (where clinical guidance is held, and also covers safeguarding issues) section on the crew staff tablets, which has to be acknowledged as received.

Bulletins are attached into this app so they can be seen by all staff. It will also alert them, when they next open the app, that there is something they have not yet read.

In addition, EOC staff receive weekly emails with all bulletins attached.

Updates to Policies OP14 and OP23

We gave evidence at the inquest that national guidance for dealing with missing/absconded patients was issued to ambulance Trusts in April 2021. Although our policies OP14 and OP23 are already compliant with that guidance, it was accepted in evidence that it would be beneficial to update them to include a specific step by step process to be actioned by control room in conjunction with frontline staff.

Both policies, OP14 and OP23, were already in the process of being updated prior to this case. The learning from this case will be incorporated into the updated policies, in corresponding wording to the respective bulletins.

Work was already underway to make OP14 a unified document that would be a single ‘point of truth’ for information when staff have a specific policy or clinical question, with hyperlinks to relevant information and documents. This means that it will be a ‘live’ document on line which can be updated quickly. It can be accessed by staff via their tablets when on scene.

Policy OP14 is expected to be finalised by the end of 2021, and OP23 is expected to be finalised in early 2022. When the new policies are released, this will be communicated in the same ways

as the staff bulletins, as set out above. New starters will also be provided with them and the policies will be embedded in training for new entrants to the relevant teams at LAS.

I hope this response is helpful in describing the immediate and ongoing work the LAS is engaged in relating to ‘no trace’ calls involving vulnerable patients, encompassing bulletins for both frontline and control room staff, and corresponding amendments to our policies for those groups of staff.

Dear Mr Laundau, Re: Regulation 28 Report to Prevent Future Deaths – Richard Boateng who died on 31 March 2021. Thank you for your Regulation 28 Report (hereinafter ‘Report’) dated 28 November 2021 concerning the death of Mr Richard Boateng on 31 March 2021. Firstly, I would like to express my deep condolences to Mr Boateng’s’s family. I note the conclusion of the recent inquest was as follows: Mr Richard Boateng phoned his GP surgery on 30 March 2020. He was very unwell. A GP called him the next morning and although he answered the phone, he was not able to complete sentences or give his full name. He was on a bench in the street from at least 10.30am that day. Police were called and attended at 4pm. An ambulance arrived at 6.23. Despite attempts at resuscitation, Richard died from Covid 19 shortly after his arrival at Croydon University Hospital on the evening of 31 March 2021. Following the inquest you raised concerns in your Report to NHS England regarding: A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinic which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments, and there is no guidance available to surgeries as to how to mitigate the risks of this. GP practices employ non-clinical staff in receptionist roles. The receptionist role is vitally important as first point of contact for patients and has long been relied on to National Medical Director and Interim Chief Executive, NHS Improvement Skipton House 80 London Road London SE1 6LH 18th February 2022

manage requests for urgent and routine appointments, and patients who may call with medical emergencies. It is the responsibility of each individual GP practice to ensure all staff are suitably trained and experienced to undertake the tasks that they are delegated. I can confirm that ‘Care Navigation’ as undertaken by receptionists, was fully supported in the NHSE GP Forward View, with further training material and funding provided to support its implementation: https://www.england.nhs.uk/blog/plotting-the- right-path-with-care-navigators/. We have developed a training pack for administrative staff which is intended to help support them with information gathering, care navigation and identifying emergency symptoms. The training pack is attached. We are also currently working with Health Education England (HEE) to develop a training programme for both clinical and non-clinical staff to support them further. I can confirm that a significant increase in remote triaging, as used in general practice during the Covid-19 pandemic, has introduced a number of digital triage platforms and processes which can further support care navigation, including management of ‘red flag’ symptoms. From a digital tools perspective, suppliers and deploying organisations (with support from their clinical safety officers) need to comply with clinical safety risk assessment standards. We have developed and made available a draft hazard log for digital total triage, a clinical safety risk assessment template for practices and commissioners and further assurance guidance is attached.

NHSEI also have a clinical safety officer forum where we discuss risks and issues, and collaboratively look at preventative measures. Our Digital First Primary Care (DFPC) guidance for the implementation of Online Consultations puts a lot of focus on safety, though not specifically on the role of non- clinical staff: https://www.england.nhs.uk/wp-content/uploads/2020/01/online- consultations-implementation-toolkit-v1.1-updated.pdf. This provides guidance on:
• Safety and clinical risk management standards for Suppliers on the Dynamic Purchasing System framework are required to meet.
• Code of conduct for practices, including on Risk management, Clinical safety officers, Reporting incidents and near misses and more.
• Guidance to Practices to not rely on online access for all clinical triage and that in some practices, admin staff do directly schedule an appointment without the need for triage, with examples such as: Need for a clinical examination, investigation or collection of certain physiological data to provide safe care; A high risk of deterioration.

Thank you for bringing this important patient safety issue to my attention, and I do hope the above information sets out the work that we at NHSEI have been doing in

answer to your concern. Please do not hesitate to contact me should you need any further information.