Dear Sir Re: Inquest touching the death of Mark Bennett I write on behalf of Yorkshire Ambulance Service NHS Trust (YAS) and in response to the Regulation 28 report on this matter, issued on 26 September 2023 and received by Yorkshire Ambulance Service NHS Trust (YAS) on 23 October. 2023. I am aware of the circumstances of Mr Bennett’s tragic death and take this opportunity to offer my sincere condolences. Your matter of concern was: “I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should the patient be taken to hospital for thrombolysis.” I understand this relates to the clinical management of a patient in cardiac arrest who has a suspected pulmonary thromboembolism (PE). Nationally, ambulance clinicians follow standard clinical practice guidelines developed and managed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) on behalf of the Association of Ambulance Chief Executives (AACE). These are universally referred to as the JRCALC Guidelines. Guidelines relating to the management of cardiac arrest follow the Resuscitation Council (UK) guidelines. The guidelines are clear on the delivery of Advanced Life Support (ALS) and when to consider that to commence or continue resuscitation attempts would be futile. YAS clinicians have the ability at all times to access these guidelines via an app on a personal issue YAS mobile phone.

In this instance the potential cause of cardiac arrest being a PE was recognised by the attending paramedic. PE is one of the potentially reversible causes of cardiac arrest described in the JRCALC guidelines. ALS requires exclusion or treatment of a potentially reversible cause before resuscitation attempts should cease. If appropriate treatment cannot be provided in the pre-hospital environment, then the patient should be conveyed to the nearest Emergency Department, with cardiopulmonary resuscitation (CPR) ongoing, without delay. Paramedics are also supported to make decisions about the futility of commencing or continuing resuscitation attempts and JRCALC provides clear guidance on the scope in which paramedics may make these difficult decisions. Unfortunately, in this instance, but clearly with the best of intentions, a decision was made which falls outside that scope. On review, YAS documentation could be more supportive in making these decisions. To that end, I have asked that the clinical documentation is reviewed and updated, and decisions relating to the termination of resuscitation attempts are covered as a component of annual clinical refresher training. My thoughts remain with Mr Bennett’s family.

Dear Mr Eccelston

MARK BENNETT (DECEASED)

I am writing in response to the preventing future deaths report we received at the Association of Ambulance Chief Executives (AACE) dated 19th September 2023, and I respond as the Director of Operational Development and Quality Improvement on behalf of the AACE.

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub- groups.

With regard to your matter of concern relating to ambulance services and resuscitation:

Lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis.

With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes. The guidance currently contains specific wording in relation to pulseless electrical activity:

Young age, myocardial infarction and potentially reversible causes of cardiac arrest, such as hypothermia and pulmonary emboli, are associated with a better outcome, especially when the arrest is witnessed and followed by prompt and effective resuscitative efforts.

Within the advanced life support guidance there is a section of guidance on reversible causes and specialist circumstances in cardiac arrest - commonly known as the 4Hs and 4Ts. One of the reversible

causes to consider is that the patient may have a coronary or pulmonary thrombosis. The current wording states:

Thrombosis-Coronary or Pulmonary Pulmonary This will be challenging to diagnose in the cardiac arrest situation. If available, the patient’s history before cardiac arrest may give some indication. If pulmonary thrombosis is suspected, a time-critical transfer to hospital is indicated. In situations where thrombolysis is administered, CPR for as long as 90 mins may be required to break up the clot. In these circumstances, consider mechanical CPR. Intra-arrest thrombolysis can be considered if available: follow local pathways but do not delay conveyance to hospital.

AACE are not responsible for the training or education of ambulance staff, however we are aware that ambulance trusts have a responsibility to ensure that staff that attend cardiac arrests are adequately trained and that this training is regularly updated.

The JRCALC guidelines are produced to assist UK Paramedics undertake their role effectively. We appreciate that our clinicians have to make difficult decisions around resuscitation practice, especially in relation to when to commence and when to terminate resuscitation. Many factors need to be taken into account, often rapidly and during stressful situations. We are continually reviewing and updating all our guidance on a regular basis and when new evidence becomes available.

We are supportive and engaged with a current and ongoing National Institute for Health Research funded study titled: Exploring and improving resuscitation decisions in out of hospital cardiac arrest. The study aims to determine what is the best approach for deciding when and where to stop resuscitation attempts. Presentation of research findings to a stakeholder group took place on 18th October 23 of which a number of AACE representatives attended. The output from this research will be an evidence informed, ethically grounded, termination of resuscitation guideline, which is acceptable to NHS staff, patients and their relatives. Subject to relevant approval processes, we anticipate that the results of this study may lead to an update to our JRCALC guidance leading to better decisions for patients and their relatives.

On behalf of AACE, I would like to extend our sincere condolences to the family of Mark Bennett.

I hope this response has adequately addressed the concerns that you have raised. If you have any further questions please do not hesitate to get in touch.