Dear Mr Bridgman

Re: Regulation 28 Report into the death of Martin Sullivan

We are writing in response to your Regulation 28 letter dated 2 March 2021 in relation to the death of Martin Keith Sullivan. We note the areas of concern that you have raised and address each of them below. In preparing this response we have liaised with NWAS to provide additional information and context to the matters of concern. At this time, as Commissioners, we also wish to formally take the opportunity to express our deepest sympathies to Martin’s family in addressing the concerns you have raised.

1 . and 2. The MPDS Algorithm and Rule 6

The choice of which clinical decision support tool to operate in the 999 environment lies with NWAS as the ambulance service provider. MPDS is an internationally developed and accredited tool provided by the International Academies of Emergency Dispatch (IAED) and is used by several UK ambulance services. The outcomes reached after MPDS assessment are aligned to the ambulance response categories. These are nationally determined and not set by NWAS or commissioners.

The identification of ineffective breathing, which would receive a Category 1 response, is an ongoing challenge to all ambulance services. Historically call takers were required to remember phrases or words given by the caller that indicated the patient was suffering from ineffective breathing.

NWAS established an internal task and finish group in 2019 to understand the issues in more detail and to feed into the national review process. On reviewing the outcomes of this task and finish group NWAS decided that further work was still required to further improve the identification of ineffective breathing and there was wider recognition of the issue. This has been taken forward nationally as this is a theme raised by all Ambulance Trusts utilising MPDS. NWAS, alongside other ambulance trusts, are part of a national working group to agree revisions to MPDS standards, including the identification and recognition of the importance of ineffective breathing.

A series of actions were taken in January 2020 to further improve the responsiveness to calls involving ineffective breathing and are summarised as follows: -

• training of all their call takers, along with issuing operational educational bulletins and 1:1 introducing an electronic ‘pop up’ to aid call takers in identifying ineffective breathing
• Staff bulletins issued to reinforce where and how ineffective breathing should be identified

• A review and reissuing of training packages
• Further and ongoing thematic analysis and reporting
• NWAS developed a simulation-based online training platform, which is waiting to go live, coupled within a focused communications campaign within each of the NWAS Emergency Operations Centres (EOCs)

Progress against these actions is regularly reviewed at each monthly meeting of the commissioner-led Regional Clinical Quality Assurance Committee (RCQAC) to ensure that actions continue to be taken, and to support NWAS in national discussions on the ineffective breathing MPDS algorithm and working closely with the IAED to establish best practice for the identification of ineffective breathing and developing processes that will further reduce future risk.

The current position is that as of January 2021 NWAS perform similarly to other ambulance services in this regard and are not a national outlier in recognition of ineffective breathing.

3. Service Performance and Contracting

In terms of addressing your concerns regarding the performance of the service we felt it would be helpful to compare NWAS performance against the other ambulance trusts for the time in question. In the week in which the incident occurred no ambulance service nationally achieved the Category 1 mean response standard, and only 2 of the 11 trusts achieved the Category 2 mean response standard. Included in the appendix is a visual representation based on national data that shows this position.

All ambulance trusts principally achieve the Category 1 90th percentile standard, but again only 2 ambulance trusts achieved the Category 2 90th percentile standard in the week in question. This highlights the significant operational pressures all ambulance services were facing at the time and the challenges adapting to the new service models needed for the Ambulance Response Programme (ARP) approach nationally adopted in August 2017 (Appendix 1).

In terms of addressing your concerns regarding the funding that is placed to allow NWAS to deliver the service, we have summarised the contacting process as follows. On an annual basis, in line with the requirements of the annually published NHSE/I Planning Guidance, discussion meetings are held between commissioners and NWAS. Their purpose is to negotiate and agree the contract both in terms of cost, volumes of activity based on previous funding levels, achievement of performance standards and agreed internal transformation plans in line with the national Planning Guidance requirements.

The starting point for this is the historical cost of the service, any anticipated increases in overall demand for the service, how the demand is balanced across the acuity of patients and how NWAS respond to the demand managing incidents appropriately. This covers increasing the number of options for patients who would elicit a Hear and Treat and/or See and Treat response to reduce avoidable conveyance. These and other initiatives are designed to ensure that the patient is directed first time to the most clinically appropriate service (only in the cases where a category 1 or 2 response is not clinically indicated). These initiatives are designed to support improvement in ambulance response times and release increased capacity for those patients who do require a category 1 or 2 response and conveyance to hospital. Having agreed the contract, it is then a matter for the trust to determine, operationally, how it will respond to demand and deliver the national standards expected of it. Over the course of each contract year commissioners meet regularly with the trust to monitor levels of demand, performance being achieved and patient safety, and there is a well-defined governance structure in place to enable this to happen.

The investment over recent years has been in response to changes in demand and the national Ambulance Response Programme (ARP) standards that were introduced in August 2017. This replaced the previous targets with a fairer system whereby ambulance trusts would be measured on both their mean and their 90th percentile performance for each category of patient. Commissioners have invested significantly in the ambulance service since the introduction of the ARP standards.

The contract is based on achievement of the national ARP Targets at a North West level. This is in line with national policy and remains the current position. We have set out below a summary of the investment made by commissioners between 2016/17 to March 2019/20. This is summarised in table 1 below.

Table 1 – Commissioner investment agreed with NWAS Total NWAS Funding Available £ Year on Year Growth Growth since 2016/17 2016/17 222,910,434

2017/18 248,735,780
11.6%

2018/19 261,393,154
5.1%

2019/20 283,349,758
8.4%
27.1%

Note: The majority of the funding available to NWAS is for use by them in delivering front line services. A small proportion of the overall funding is for specific use including funding such as Hazardous Area Response Teams (HART) and targeted support over the winter periods.

At the point of contract agreement, it is then for NWAS to implement an approach that will deliver the outcomes agreed, i.e. ARP standards. Commissioners do not specifically determine how many ambulances they have, where these are distributed, what shift times they operate and so on. This level of operational detail is down to internal NWAS planning and service delivery.

The specific point raised in your letter of NWAS seeking additional investment in November 2019 and being utilised from February 2020 is not recognised by commissioners as an external funding issue. As stated above it remains for NWAS to determine in year any shift in allocations of funding flexibly within and across the Trust to maintain patient safety and achieve the national performance standards, performance, and patient safety. Therefore, we are unable to comment further on the point made as this was not a request made by NWAS to commissioners and our understanding is that this would be an internal operational matter for NWAS.

We monitor performance by sector, sub-regional and on an overall regional trust performance daily. In terms of the actual deployment of resources this remains as described a matter for NWAS to operationally manage. We have asked NWAS to provide additional information on the activity on the day in relation to resources deployed at trust sub-regional and sector level at the time of this tragic incident. On the day of the incident at 06:22 between the first and second call NWAS had 162 incidents awaiting allocation – a high number of which were C2. Of the 162 waiting incidents, 82 were in GM.

Planned resources are determined by NWAS and based on predicted activity for the particular day. Of the 6 ambulances on duty in the Oldham sector at 06:16, when the call for this patient was received, 1 was unavailable in line with the Meal & Rest Break policy and finished shift at 06:30, and the remaining resources were already committed to incidents. The 1 unavailable resource finished shift at 06:30 and after the day shift commenced, was allocated to a longer waiting category 2 incident. A further 2 resources cleared during the call cycle but were unavailable in line with Meal & Rest Break policy. Both of these resources finished shift at 07:00.

The availability of resources to respond to the incident in question and any impact of the changing daily profile is a matter for NWAS. However, the level of planned responding resources will vary due to the time of day in relation to predicated levels of activity and the level of demand at different times of the day (Appendix 2).

As commissioners we are responsible for holding NWAS to account for the achievement of the ARP standards. In the monthly contracting meetings, we highlight any issues of performance and strive to work

with the trust to improve their performance, recognising any challenges and seek to agree remedial action plans within the contract terms and conditions.

Following extreme pressure on the service in early November 2020 NWAS reviewed the effectiveness and appropriateness of their Demand Management Plan (DMP) in place at the time and the triggers and actions aligned to them. The DMP was subsequently replaced with a new Patient Safety Plan (PSP) on 26th November 2020. The aim of the PSP is to enable NWAS to respond earlier in terms of escalation in a timely and appropriate manner to increased service pressure, enabling an NWAS wide response as soon as identified triggers are met.

The trigger thresholds from the DMP in many areas have been reduced to assist earlier implementation of actions to reduce the number of calls waiting and improve service responsiveness. The PSP is more interactive with the local health care economy as well as internally across NWAS, including NHS 111 and Patient Transport Service.

In conclusion we acknowledge the findings made at the Inquest that there were issues with the prioritisation of the call and that on the day NWAS were unable to allocate resources to ensure Martin received care within the ARP target time. In our response we have sought to provide additional details and information to give assurance that there is and has been active, detailed work undertaken to address a nationally recognised challenge in relation to the identification of patients with ineffective breathing. This work continues and receives regular oversight through our clinical governance and quality interactions with the trust. In addition, we have sought to provide more detailed information with regards to the funding of NWAS and the contractual relationship between commissioners and the trust.

Dear Mr Bridgman,

Re: Regulation 28 Report to Prevent Future Deaths – Martin Keith Sullivan (24 November 2019)

Thank you for your Regulation 28 Report dated 2 March 2021 concerning the death of Martin Sullivan on 24 November 2019. Firstly, I would like to express my deep condolences to Martin’s family.

The Regulation 28 Report concludes Martin Sullivan’s death was a result of multiple organ failure.

Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the MPDS script and algorithm.

MPDS has been in operation across the world triaging millions of 999 calls since
1979. The International Academy Emergency Despatch continually reviews and updates the 36 protocols covering the full range of emergency call reasons from Abdominal Pain and Burns to a specific pandemic protocol. One of the fundamental principles of the triage tool is the identification of priority symptoms such as choking or breathing problems. The MPDS algorithm, where applicable, does combine answers to questions to determine a higher level of acuity. Emergency Medical

NHS England and NHS Improvement Despatchers (999 call handlers or EMDs) are trained to elicit the main reason for the emergency call using a number of different methods, set out below.

The case entry process establishes the main reason for the emergency call and is referred to as chief complaint selection (this is which of the 36 protocols to choose); it is also designed to elicit the level of consciousness and breathing status. This leads to the early identification of patients in, or at risk of, airway obstruction, life threatening breathing compromise, and cardiac arrest.

The use of an open-ended question at the beginning of the call has been proven to elicit an appropriate response from the caller to enable appropriate categorisation. “Tell me exactly what’s happened?” gives the caller the opportunity to state why they have called. This information is combined with the responses to specific questions about breathing.

The understanding of ineffective breathing and its trigger phrases is a crucial part of using the MPDS system, and EMDs must have a thorough understanding of what ineffective breathing means. In the context of a patient with severe respiratory distress, on most occasions the caller will answer with some form of description of the breathing problem. Research of millions of emergency calls led to the development of trigger phrases, or any reasonable alternatives, as descriptors for ineffective breathing. The eight phrases cover a wide spectrum of life threatening respiratory compromise from ‘turning blue’, ‘barely breathing’ to ‘can’t breathe at all’. These patients are recognised as fighting for air and have ineffective breathing. If a description of the patients breathing is not offered as part of “Tell me exactly what’s happened” it is then directly asked in case entry, is s/he breathing?”

EMDs are trained in active listening, and it is vital they use this skill throughout the entirety of the call for any information that is offered; this may be additional information relevant to a previous answer which could indicate deterioration or provide the answer to a later question that does not now need to be repeated. The identification that the patient has asthma is of relevance to identifying ineffective breathing, as the threshold for asthma patients to be identified as ineffective breathing is lower. Rule 6 protocol 6 sets out very clearly:

Asthma patients are usually very experienced in managing their disease. When the status of these patients is reported “Can’t breathe”, “Unable to breathe”, or similar description this should be considered INEFFECTIVE BREATHING

It is not the case that the system is relying on the information being offered/volunteered but rather that the questions within Protocol 6 will elicit the information required. It is in response to both the open and closed questions that the EMD must recognise ineffective breathing in a patient with asthma. When applied correctly this is a very reliable method of determining life threatening respiratory distress including life threatening asthma. Any patient who is identified as ineffective breathing should receive a category 1 response. Acute severe asthma

NHS England and NHS Improvement is allocated a category 2 emergency response. This reflects the absolute urgency for patients with ineffective breathing.

As per MPDS procedure, any patient with severe breathing problems who is at risk of deterioration the EMD is required to stay on the line and monitor for deterioration. Information gained during this period should be triaged accordingly; additional information such as “he can’t breathe properly” (Rule 6 for Asthma patients) should be upgraded to a category 1 response.

For the reasons set out above, it is the view of NHS England and NHS Improvement that the algorithm, when used correctly, does identify life threatening asthma and will result in a Category 1 response.

In order to ensure that the process of identifying ineffective breathing is embedded within all ambulance services NHS England and NHS Improvement will hold a learning event with all ambulance services, inviting the involvement of triage system providers, to share best practice and ensure ambulance services are enabled to utilise the triage systems safely and effectively.

Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.