Dear Mr Fisher Re: Report to Prevent Future Deaths Stuart Knight (DECEASED) am writing in response to your Regulation 28 Report to Prevent Future Deaths_ dated 22nd September 2015, bringing to my attention the Coroners concerns arising from the inquest into the death of Stuart Knight: Firstly, can begin by assuring you that within East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. Assurance around the availability of an ambulance in a timely manner to those requiring emergency aid is at the heart of our purpose Your report and Prevention of Future Death notice pertaining to the inquest into the death of Stuart Knight stated the following in relation to the service provided by EMAS to Mr Knight: Significant & unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS have included some additional detail, including our record of the chronology in relation to our care of Mr Knight in a detailed response in the enclosed appendix_ However, also wanted to respond to the specific points you have raised and have set these out in the following paragraphs, which trust is helpful in providing the assurance you seek: the

East Midlands Ambulance Service NHS NHS Trust Emergency Care Urgent Care We Care Background East Midlands Ambulance Service (EMAS) serves a resident population of 4.8million across the East Midlands region (Derbyshire , Leicestershire and Rutland, Lincolnshire (including North and North East), Northamptonshire and Nottinghamshire), across 6,425 square miles. Each year we respond to over 616,000 emergency and urgent calls_ Allocation of response Calls to Ambulance services are coded to medical priority, matching government criteria In addition every ambulance service is required to report on response times to each type of call: A summary of this requirement is detailed in appendix 1 In response to the issues raised at the inquest into the unfortunate death of Mr Knight we would respectfully submit the following points as actions we are taking to improve our service Investment in Staff East Midlands Ambulance Service has made significant investment in both staff and vehicle resources since 2014 in both "frontline" staff who attend 999 calls but also in staffing within the emergency operations centre_ This recruitment has been supported with investment in our education centres to facilitate training from Emergency Care Assistant; through Ambulance Technician and ultimately to Paramedic level. Staff work on allocated rota lines with a percentage (around 12% in Lincolnshire) working on relief where can be deployed flexibly to work shifts where expected demand exceeds our core rota deployment output: In this way extra resources can be deployed dynamically to ensure availability through periods of predicted high demand. 2_ Fleet Provision In addition we have invested in our fleet provision to increase the number of vehicles we have available allowing the trust to deploy more resources at any one time. A comparative summary of our staffing and fleet provision from August 2014 to the current year is detailed in appendix 2_
3. Clinical Tools to support staff We have supported our frontline staff with the introduction of Paramedic Pathfinder (PP) PP is a pre hospital assessment guide based around the widely used NEWS (National early warning system) designed to assist crews to identify patients that are suitable for onward referral as opposed to transport to the emergency department Typically when a patient is not conveyed from their home address (See and Treat) , the job cycle time (total time the ambulance is dealing with that particular call and is therefore unavailable) is reduced. Starting in April 2014, by October 2015 94% of staff have completed the training: For the longer term this translates into a project based on Commissioning for Quality and Innovation (CQUIN) money to develop specialist pathfinder tools for specific conditions ultimately to identify and they

East Midlands Ambulance Service WNHS] NHS Trust Emergency Care Urgent Care We Care develop referral services to accept patients and thus negate the need to transport the patient to the emergency department: This will ultimately increase "see and treat" levels and reduce job cycle time_ Clinical Assessment Team We have invested significantly in the scope of our Clinical Assessment Team (CAT) based in the emergency operations centre_ The CAT team are a group of clinicians, qualified Paramedics and Nurses who work within the EOC on a 24 hour per week rota: work providing support and telephone assessment to 999 calls received by the trust: The result of the telephone assessment can, in some serious cases, ensure that a call is dealt with as higher priority due to clinical need or, in other cases, result in the call being dealt with to a conclusion by the CAT clinician: This is termed as "hear and treat" . In dealing with calls in this manner this ensures that frontline resources are not sent if not required therefore making them available to mobilise to patients with more serious clinical need that require immediate treatment or transport. As a direct comparison of August 2014 and August 2015 within Lincolnshire an additional 1200 calls were dealt with via hear and treat negating the need for face to face consultation therefore increasing ambulance availability. Specific Initiatives As a local initiative between the Trust and the commissioning group in east Lincolnshire , a single Ambulance Technician vehicle is available to be deployed dynamically to calls where a traditional double crewed ambulance may not be required, for example a non-injury fall requiring assistance. Supported by the CAT team this resource can suitable respond to a call and through CAT refer or discharge at scene, again negating the need for an ambulance to be deployed The scheme covers both the Skegness and Boston areas and has run April 2015 with the following attendances On average this initiative allows around 40 calls per month to be appropriately and safely assisted, referred and discharged without the need for the attendance of an emergency ambulance_ A summary of both our "hear and treat" and the CAT car initiative activity can be seen in appendix 3_ Through local initiative, central trust-wide strategy and CQUIN funded project work; the continued emphasis of the Trust is to make ambulances available to those with high clinical need. This is accomplished by both increasing staff numbers and vehicles to ensure there are enough resources available at any given time. Similarly initiatives are in place and being developed to ensure that calls received not requiring an ambulance attendance are dealt with safely and appropriately in alternative ways that do not add unnecessary demand onto emergency staff and vehicles_ We hope that the significant investment in our front line resources which we are working to complete by March 2016 should reduce the chances of the significant that occurred in this unfortunate case_ trust that this information is helpful but please do not hesitate to contact me if you require anything further.