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Report in Response to Coroner’s Regulation 28 Report – Matters of Concern Date: 7th July 2025 Prepared by: , Facilities and Compliance Lead Organisation: Kent Central Ambulance Service

Introduction This report is prepared in response to the concerns raised under Regulation 28 following the inquest into the death of Emily Rose Stokes from MDMA Toxicity. Emily had made plans to meet friends at the Worried about Henry at Dreamlands music festival in Margate, on the 29th of June 2024. The findings of the coroner have been taken with the utmost seriousness. As a healthcare provider, Kent Central Ambulance Service is committed to continuous learning, service improvement, and ensuring the highest standards of patient safety, comfort and care. This document outlines the specific concerns raised by the coroner and details of the actions taken and planned by Kent Central Ambulance Service to address these concerns and implement robust corrective measures. Summary of Matters of Concern The coroner raised the following key issues:
1. Training and suitability of ambulance staff – Concerns about the ambulance crew that attended the event were minimally trained and not equipped to manage high-risk environments involving possible drug use.
2. Clarity of responsibility for pre-alerting the hospital – Ambiguity regarding whether the responsibility to pre-alert the receiving hospital lay with the paramedics or the private ambulance crew.
3. Adequacy of ambulance equipment – The vehicle used was not considered to be fully equipped in comparison to NHS ambulances.

Kent Central Ambulance

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Kent Central Ambulance provide Non-Emergency patient transport for Maidstone & Tunbridge Wells NHS Trust. The nature of the work includes the transportation of patients requiring transport to or from a trust site to other hospitals, nursing homes, hospices and any other location as determined by the Trust. We also cover event around the Kent & Medway Region. Our service provisions for NEPTS will include High Dependency, Bariatric patient, Stretcher and Wheelchair patient transfers. Our ambulance crew responsibilities will include but are not limited to:
• Ensure that patients are transported in the following way
• In safe and timely manner in a vehicle appropriate to their needs,
• They are collected promptly, in reasonable timescales,
• They are treated with courtesy, dignity, and respect at all times
• There will be no detriment to the patient’s health and wellbeing during their journey. Our Staff Training & Skill Set Our training protocols encompass two distinct formats: online modules and in-person classroom sessions. The training program has been developed to ensure staff members can develop in a supportive environment and undertake courses that will improve their capabilities and improve patient care. Taking into consideration other qualifications gained, previous experience, the needs and demands of the business.

We also provide Clinical Helpline support via our partnership with BEARS ambulance service, this is an immediate helpline for our ambulance crews in the event they encounter and challenging situation, for immediate guidance and support in the event they need support following a traumatic experience.

At KCAS, the grade of staff undertaking High dependency (HD) journeys or transporting service users in an emergency would be.

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Ambulance Care Attendant (ACA) – First Responder Emergency Care Level 3, with medical escort and the patient has been risk assessed by a clinician at the discharging hospital.

Clinical Role: Scope of Practice: Intended case load: Ambulanc e Care Assistant (ACA) FPOS(i) or FREC 3 Oxygen and Entonox Therapy PTS and Blue Light Emergency Driving Cardiac Monitoring (3 lead ECG) Basic Rhythm Recognition LifePak 12/15 Automated Defibrillation Oropharyngeal/Nasopharyngeal Airways Suction (Handheld/Laerdal Suction Unit) Recognition of Tracheostomy Emergencies BLS, PBLS & BVM Manual Handling Bariatric Handling MIBS Stretcher Safeguarding Referrals Tourniquet for Cat. Haemorrhage Selected experienced ACAs to act as mentors and sponsors for new recruits to assist in the signing off for:
• Shadowing
• Practical use of Equipment
• Safe Systems of Working All staff are required to complete the Online Training as detailed attached Patient Transport/Non- emergency journeys. Risk Assessed High Dependency Journeys not requiring a Paramedic, and as below:
• High Dependency Journeys with a Medical escort.
• Running Calls.
• Bariatric Patients.
• Informal MH Patients. High Dependency Journeys are defined in contract as:
• Stroke patient being transferred for immediate or emergency treatment.
• Suffering from continuous epistaxis requiring treatment or surgery.
• Patients with quinsy post treatment to secondary facility.
• Sickle Cell patient, hypoxic or requiring Oxygen.
• Tracheostomy in situ.
• Level 1 and 2 Critical care Patients.
• End of Life or Palliative care patient.
• Patients >5l Oxygen required.
• Patients requiring Suctioning, Entonox, Observations inc. cardiac monitoring.
• Blue light transfer authorised by Doctor or Senior Nurse.
• Paediatric Pt requiring Pedi- mate, Pod (or Incubator with Medical Escort).
• Patients with locked off/disabled syringe drivers or pumps.

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Emergency Care Attendant – First Responder Emergency Care Level 4 (FREC4) with medical escort and the patient has been risk assessed by a clinician at the discharging hospital.

Clinical Role: Scope of Practice: Intended case load: Emergency Care Assistant (ECA) FPOS(e) or FREC 4 Oxygen and Entonox Therapy Blue Light Emergency Driving Cardiac Monitoring (3 lead ECG) Basic Rhythm Recognition LifePak 12/15 Automated Defibrillation Oropharyngeal/Nasopharyngeal Airways Suction (Handheld/Laerdal Suction Unit) Recognition of Tracheostomy Emergencies BLS, PBLS & BVM Manual Handling Bariatric Handling MIBS Stretcher Safeguarding Referrals Tourniquet for Cat. Haemorrhage Selected experienced ECAs to act as mentors and sponsors for new recruits to assist in the signing off for: Shadowing Practical use of Equipment Safe Systems of Working All staff are required to complete the Online Training as detailed attached: Patient Transport/Non-emergency journeys. Risk Assessed High Dependency Journeys not requiring a Paramedic, and as below:
• High Dependency Journeys with a Medical escort.
• Running Calls.
• Bariatric Patients.
• Informal MH Patients. High Dependency Journeys are defined in contract as:
• Stroke patient being transferred for immediate or emergency treatment.
• Suffering from continuous epistaxis requiring treatment or surgery.
• Sickle Cell patient, hypoxic or requiring Oxygen.
• Tracheostomy in situ.
• Level 1& 2 Critical care Patients.
• End of Life or Palliative care patient.
• Patients >5l Oxygen required.
• Patients requiring Suctioning, Entonox, Observations inc. Cardiac monitoring.
• Blue light transfer authorised by Doctor or Senior Nurse.
• Paediatric Pt requiring Pedi- mate, Pod (or Incubator with Medical Escort).
• Patients with locked off/disabled syringe drivers or pumps.

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Online training for all staff includes Fire safety; Health and Safety; Infection Prevention and Control; Dementia; Mental Capacity Act and DOLS; Safeguarding Adults; Safeguarding Children; Moving and Handling People; Conflict Management & Resolution; Data Protection; Counter fraud in the NHS. Response to Identified Concerns
1. Staff Training and Preparedness for High-Risk Events We confirm that the staff deployed on the day were trained and certified according to their roles. However, on reflection, we recognise that deployment of our staff to events where there was an increased likelihood of young persons in attendance coupled with the potential for illicit substance use, required a higher level of specific and scenario-based training. Actions Taken: An evaluation of previous approach to accepting events coverage has been completed and as part of our learning we have put in pace the following: Process Step Change: For all event coverage booking request:
a. Clarity and engagement with the Event Management team to scope the requirement, support on the day, number of spectators, age group and type of event
b. We evaluate our suitability for the service; this exercise is conducted by our senior management team with the support of the clinical lead to scope and confirm that our resource capability for the service requirement.
c. We complete a risk matrix to understand likely /unlikely risk during event and match this to our scope of practice.
d. A team of experienced staff is then established to cover public events, depending on the following groupings: especially those involving young persons or known drug-risk environments.
• These staff will receive enhanced training, covering: o Recognition of drug and alcohol intoxication o Clinical red flags and deterioration signs o Communication and escalation protocols o Situational awareness and de-escalation o Responding to medical emergencies in dynamic settings

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2. Clinical Decision-Making and Pre-Alert Protocol On the day of the incident, the attending crew identified concerns and sought to escalate via a hospital pre-alert. However, direction was given by on-site paramedics that a pre- alert was not required, and transport was conducted without blue lights or alerting the hospital in advance. Action Taken:
• We have clarified our internal clinical escalation protocol, which now mandates that: o If a crew has any concern, they must escalate via the Clinical Support Line, regardless of other clinician directions. o Crews are now explicitly empowered to pre-alert independently if in doubt.
• All crews will receive refresher training on pre-alert criteria and documentation, with emphasis on patient safety as the guiding principle.
3. Vehicle Equipment and Suitability The vehicle used was a High Dependency Vehicle (HDV) and was staffed by a crew of two staff members. The vehicle was equipped with monitoring equipment, oxygen, resuscitation tools, and all other kit deemed appropriate for the level of care authorised under their scope. Action Taken:
• We have implemented a pre-event vehicle checklist to ensure uniformity and accountability in equipment preparation.
• A clinical inventory standard is being developed and benchmarked against NHS specifications to ensure parity wherever possible. Organisational Enhancements and Forward Planning
1. Creation of a Dedicated Event Staff Team
• A team of experienced and specially trained staff will form a core group for event deployments.
• These staff will receive dedicated event medical training and annual refreshers.

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2. Structured Pre-Event Briefings and Sign-Off On completion of our new step change process for Event Coverage, prior to any event, all staff attending will receive a formal briefing including: o Event-specific risks o Likely patient profiles o Local and on-site escalation procedures o Contact details for clinical support
• Each staff member will be required to sign off on their briefing to confirm understanding.
3. Mandatory Medical Operational Plans (MOPs)
• A comprehensive Medical Operational Plan (MOP) will now be created for each event.
• MOPs will include staffing, response structure, communication protocols, and escalation pathways.
• MOPs will be distributed to all relevant staff prior to deployment.
4. Enhanced Use of Clinical Support Line
• Staff will be re-trained on when and how to contact the Clinical Line.
• The Clinical Line will serve as a second opinion service, especially in cases of disagreement or clinical uncertainty.
5. Purple Guide Subscription and Integration
• The organisation has subscribed to the Purple Guide, an industry standard for health and safety at events.
• The guide will inform our risk assessment, staff deployment, and response framework for all future events.
6. Deployment of Event Readiness Checklist
• All crews will receive a new event checklist, covering: o Essential equipment o Key clinical signs to watch for o Contact and escalation details o Criteria for hospital pre-alert o Documentation expectations

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Learning from the Incident This incident and the Coroner’s findings will be used as a formal case study for internal learning. Key learnings will be embedded in:
• Future staff induction
• Refresher training modules
• Governance and audit processes
• Pre-event operational reviews This event will also be included in our annual Clinical Governance Review and form part of wider quality improvement projects. Commitment to Ongoing Improvement We recognise the tragic nature of this incident and the need for continued service improvement. Our organisation is committed to:
• Ensuring staff readiness for all deployment environments
• Strengthening communication and escalation protocols
• Upholding a high standard of clinical responsibility and patient safety This report outlines the meaningful steps we are taking to respond to the Coroner’s concerns and implement lasting change. We remain open to any further recommendations and welcome ongoing dialogue with relevant bodies.

Prepared by: Facilities and Compliance Lead Kent Central Ambulance Service 7th July 2025