Dear Ms Richards,

Inquest into the death of Sophie Jayne Wilson Regulation 28 – Report to prevent future deaths I am writing in my role as Chief Executive of North East Ambulance Service NHS Foundation Trust ("NEAS") in response to the Regulation 28 report for the prevention of future deaths dated 2nd August 2024 as issued by you following the inquest into the tragic death of Sophie Jayne Wilson. I am sorry that you have had to raise concerns with NEAS following the inquest and would like to take this opportunity to pass my sincere condolences to the family of Sophie. The matters of concern listed in your report are: -
1. Although I received reassurance following the internal investigation that actions have been completed and lessons learnt in relation to this death, I remain concerned about the fact that the ambulance crew and paramedic were entirely unaware of the familiar faces plan in place for Sophie which contained crucially important information pertinent as to how best to assist her, secure her engagement and in relation to issues of both capacity and risk. I was told in evidence that the difficulty related to a data limit upon the electronic devices utilised by NEAS, and that therefore there should be a flag on electronic communications and that the control room would need to be contacted to obtain the additional information. NEAS were a signatory to the multi-agency familiar face plan in this case which applies to them as well as a number of other agencies and was designed to assist in supporting the deceased and to reduce the risk of harm.
2. I am concerned that the information was not seen by the ambulance crew and paramedic who attended, and I am not reassured that it will be available to first responders on future occasions as it seems that the limits of the technology require the ambulance crew or paramedic to spot the flag and to contact the control room, presumably for a verbal account of the information only. I am concerned that in an emergency situation and when services are under such pressure that crucial information, such as a multi-agency familiar face plan is not easily accessible to those attempting to offer assistance to some of the most vulnerable people in society. Ambulance Headquarters Bernicia House The Waterfront Goldcrest Way Newburn Riverside Newcastle upon Tyne NE15 8NY

Tel: 0191 430 2000

Ref:

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). I will address each point you have raised in your matters of concern below: -

1. Although I received reassurance following the internal investigation that actions have been completed and lessons learnt in relation to this death, I remain concerned about the fact that the ambulance crew and paramedic were entirely unaware of the familiar faces plan in place for Sophie which contained crucially important information pertinent as to how best to assist her, secure her engagement and in relation to issues of both capacity and risk. I was told in evidence that the difficulty related to a data limit upon the electronic devices utilised by NEAS, and that therefore there should be a flag on electronic communications and that the control room would need to be contacted to obtain the additional information. NEAS were a signatory to the multi-agency familiar face plan in this case which applies to them as well as a number of other agencies and was designed to assist in supporting the deceased and to reduce the risk of harm.

I believe it may be helpful to explain the electronic devices referred to in the evidence provided during the inquest. In the first instance I understand the witness was describing the Mobile Data Terminal (MDT) which are installed in double crewed emergency ambulances and emergency rapid response vehicles. These terminals, commonly referred to as Terrafix, are secured and hard wired into the vehicles in line with Road Vehicle (Construction and Use) Regulations 1986 and provide ambulance crews with satellite mapping/navigation to the scene of the emergency call alongside basic functions which track arrival/departure of the vehicle at scene and one way messaging from our Emergency Operations Centre (EOC). The latter one-way communication is a “flag” which presents messages on the MDT screen showing basic information to our staff while they are enroute to the incident.

The second relevant electronic device is an iPad which is used to access the electronic Patient Care Record (ePCR) which is the clinical record system used by emergency ambulance crews to document their contact with patient(s) as well as accessing other NHS systems to obtain additional patient information. The iPads used by emergency ambulance crews are now personal issue, following a successful trial, with the rollout of these devices commencing in August 2024, prior to this date the iPad (or previous electronic device) was part of the standard vehicle equipment. Personal issue iPads are aimed at improving and supporting the following areas:

▪ Colleagues feel more valued and are more able to keep informed with the organisation ▪ Improve access to information and communication ▪ A reduction in downtime ▪ Streamlined recording of drug, Infection Prevention Control IPC) and electronic Vehicle Daily Inspection (eVDI) audits and completion rates ▪ A reduction in maintenance costs

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). In respect to the MDT, we have now confirmed with our suppliers that the character limits on individual messages to the MDT are 1000 characters, this will however increase to 3000 characters as a part of an ongoing upgrade of the current software and hardware which is estimated to be complete by February 2025. This upgrade is part of a national programme, Emergency Services Network (ESN). The Home Office is leading this cross-government programme to deliver the ESN which is a critical communications system including multiple strands including hardware and software upgrades. This will replace the current Airwave service used by the emergency services in Great Britain (England, Wales and Scotland) and transform how we operate.

Whilst we are confident that this covers messaging requirements, an additional technical control will be introduced to split any messages into continuation messages should any exceed the specified character limit. In considering the above explanation the MDT within the vehicle is not suitable or an appropriate device to receive documents and/or for crews to use this for reading documentation, given the limitations even with the upgraded technology and software. The MDT serves a specific purpose which is predominately for satellite mapping/navigation and sending critical alerts to staff. We will go onto explain the rationale and our alternative solution to ensure staff have access to additional clinical records and information directly in the response to the second concern.
2. I am concerned that the information was not seen by the ambulance crew and paramedic who attended, and I am not reassured that it will be available to first responders on future occasions as it seems that the limits of the technology require the ambulance crew or paramedic to spot the flag and to contact the control room, presumably for a verbal account of the information only. I am concerned that in an emergency situation and when services are under such pressure that information, such as a multi-agency familiar face plan is not easily accessible to those attempting to offer assistance to some of the most vulnerable people in society. Linking into the response relating to the first concern, we are progressing with several changes to improve how our ambulance crews access additional information. This includes some medium-term specific developments targeted at the previously mentioned NEAS electronic Patient Care Record system (ePCR) which emergency ambulance crews use, via the iPad, to access and record patient details, observations, and interventions. I will go onto explain the internal work and the wider system work with partners. Whilst some of these changes are within our own gift to implement some will require development work with partners and link in with the ESN programme briefly touched upon.

In considering the fact the ambulance crew were unaware of the familiar faces plan in this case, in respect to terminology we would classify a familiar faces plan within the wider context of a special patient note or a flag. As an interim solution we have instructed our ambulance dispatch teams to verbally notify staff of any ‘flags’ placed against each case. This will enable an interaction and to seek an acknowledgement that ambulance crews have seen the ‘flag’ whilst providing an opportunity to share any additional information depending upon the type of ‘flag’.

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). It is however important to note that in times of extreme pressure our dispatch staff may not always be able make this contact, whilst balancing other priority contact with crews.

I acknowledge that this interim solution is not permanent but provides some additional controls to check that ambulance crews are aware of flags and associated information. I am sure you will appreciate that some ‘flags’ are very short such as an entry code for a key safe ranging up to those with a complex care plan shared by other organisations. In the latter we currently still rely upon this information being passed verbally to the attending crew. We will go onto explain the work we have commenced to improve this position and enable ambulance crews to directly access the information linked with any ‘flags’ such as care plans and or direct ambulance crews to other systems.

To progress the medium-term improvement work, we have created an internal task and finish group who are tasked with assessing the current process and exploring options to improve the systems and process relating to ‘special patient notes’ or simply ‘flags’ and the ability of ambulance crews to directly access this information. I can confirm that the group held the first meeting on 1st October 2024 with further meetings being scheduled to progress with the outputs from the group. It is important to note that other workstreams are linked with the task and finish group which will help triangulate the wider system improvements I have described.

Linked with these medium-term developments we have already commenced consultation with our software supplier in respect to the feasibility and timescales associated with this development. Initial engagement has been positive, and we have obtained a quote to undertake the technical development work, and a quote has now been obtained with funding identified internally. The changes are currently being considered via internal governance routes to assess potential risks and provide assurances in respect to the impact of the proposed changes. Once the NEAS subject matter expert groups, Change Approval Board and Operational Management Group, have granted approval the Executive Management Group will consider the combined expert opinions and approve the changes. Once the proposed developments have been assessed and approved, we estimate the development, testing, training, will take approximately 4-6 months to safely and effectively implement. This work will allow special patient notes and/or flags to sent directly to the iPads enabling crews to directly access the special patient note/flag linked with the specific patient and not reply upon the passage of information via radio or telephone from the Emergency Operations Centre (EOC).

Whilst the proposed improvement is being progressed, NEAS will continue to hold manually maintained flags and care plans (where these have been made available to the Trust) and re-circulate current procedures and the importance of staff to review where relevant information may be available (including GP Connect / Great North Care Record where flagged) and contact the Emergency Operations Centre (EOC) if further details are required (especially when dealing with mental health related cases). As part of the ongoing work our Special Patient Notes (SPN) team will continue to oversee and review flags and related care plans, including the duration and signoff of care plans and any associated information.

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). The existing process includes the involvement of other relevant internal and external specialists, as appropriate, to ensure flags and care plans are appropriate and correct. This process will be reviewed and updated as part of the medium-term work being undertaken by the task and finish group. During our review we have also considered the associated guidance from the Association of Ambulance Chief Executives (AACE), specifically the publication relating to ‘red flagging’ of patients with specific clinical conditions. Whilst we recognise and share the concerns around the additional workload in respect to the maintenance of flags and care plan management placed on NEAS, we believe that until an automated regional based solution can be provided, we will continue to accept care plans and flags from our partners, in the interest of aiding our crews with the delivery of patient care.

It was helpful to note that the Independent Review of the NHS undertaken by Lord Darzi has also identified concerns with the shortfall of capital investment, citing the “on top of that, there is a shortfall of £37 billion of capital investment. These missing billions are what would have been invested if the NHS had matched peer countries’ levels of capital investment in the 2010s. That sum could have prevented the backlog maintenance, modernised technology and equipment, and paid for the 40 new hospitals that were promised but which have yet to materialise. It could have rebuilt or refurbished every GP practice in the country”.. It is hoped that report will aid the wider NHS to work collaboratively to drive forward the reform and realignment to improve productivity by moving the care closer to home.

Linked with the above, our records show that the majority of care plans and flags are created by our wider system partners, a North East and North Cumbria Integrated Care Board (ICB) wide group has been established and is now meeting regularly to improve the flagging challenges and a coordinated approach to standardise and centralise the production, storage, and access to care plans for consideration by the North East and North Cumbria ICB Digital Board.

In respect to access to other clinical records, NEAS ambulance crews also have access to the GP summary information (via GP Connect) and the Great North Care Record, which is a region wide shared care record providing information associated with patients from all providers in the region. Linked with my response to your first concern, I have explained that we have instructed our ambulance dispatch teams to verbally notify staff of any ‘flags’ placed against each case. Alongside this process we will be cascading information to emergency ambulance crews in respect to the importance of accessing additional information and using the appropriate systems.

It is important to mention that both information sharing platforms, GP Connect and Great North Care Record, do not presently have full patient details or care plan documents from all providers. The North East and North Cumbria Integrated Care Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will continue to work with wider system partners to develop more effective centralised means of region wide flagging and care plan sharing.

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). I hope this response provides you and the family with the appropriate level of assurance that as a Trust we are dealing with the concerns highlighted within your report. I appreciate that it may be difficult to appreciate the technologies/systems used by NEAS especially without the benefit of visualising the devices and how they work. If it would be helpful, we would gladly arrange a visit to our Emergency Operations Centre to show you how the technology works in operational use as well as how ambulance crews use the MDT and ePCR. May I once again pass on my sincere condolences to the family of Sophie. If we can be of any further assistance then please do not hesitate to contact , Head of Regulatory Services via email at or telephone 07891 469571.