Dear Ms Combes Inquest touching the death of Mr Thomas Rawnsley (Deceased) Response to Regulation 28 Report to Prevent Future Deaths dated 9 December 2020 refer to your report dated 9 December 2020 issued under paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, as directed to Yorkshire Ambulance Service NHS Trust ("the Trust"). am aware that during the inquest hearing in November 2020 in respect of Mr Rawnsley you heard evidence on the use of Patient Information Leaflets for safety netting of patients by the Trust's clinicians and as a result a Regulation 28 Report was issued_ The purpose of this letter is to provide you with a full response to the concern as set out in your report; in so far as this is an issue which can be addressed by the Trust. set out your concern and identified action that should be taken and seek to address these below_ Matter of_concern: The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient MINDFUL

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Action that_ should be_taken: would ask that your response includes consideration of regular spot audits of a week at a time over the course of the next 12 months where paramedics are asked to take a photograph of the patient information leaflet so that this can be accurately compared with the EPR information in audit process: The Trust first introduced the Patient Information Leaflet ("PIL") as a tool to assist patients who were not conveyed following ambulance attendance in having written advice on appropriate actions to take should a change in their condition occur; generic and specific advice is prompted in the PIL. | enclose a copy of this document for your reference. acknowledge that currently copies of this leaflet are not kept within the Trust and the contents are not audited, although can say to best of my knowledge that there has been no evidence of any incidents, concerns or complaints raised on the content of the PILs to date_ The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an 'on notice' audit and results may therefore be skewed against the true position We propose to undertake an audit based on targeted request for feedback from a sample of patients treated at home to seek their views on the nature and adequacy of information and advice provided. This will serve two fold as the Trust will be in position to review the information left by the clinician, and also test the accessibility of the information to the patient in terms of it being fully understood_ The Trust's future intention is to ensure that contents of the PIL are embedded in the EPR and, when technological developments allow, the Trust will have the facility to email this entire record to the patient and their primary care provider: Additionally, and as an interim phase, the Trust will undertake the following: Review of the content of the PIL template; Spot audits of care plans documented on EPRs to (1) identify if there is a record of completion of a PIL and (2) review the quality of the advice given in the EPR; Launch of a communications campaign to staff as to the importance of detailed care plans on non-conveyance; Re-audit following this intervention; Review and development of information leaflets for specific clinical conditions e.g: head injury; and Development of 'tick box' indicators on the EPR to record information left. the the fully

would like to assure you that the Trust takes concern extremely seriously and, as learning organisation, consistently strives to improve the clinical services it delivers to patients_ Our thoughts remain with Thomas's family.

Dear Ms Combes, Re: Regulation 28 Report to Prevent Future Deaths Mr Thomas Rawnsley (4 February 2015) Thank you for your Regulation 28 Report dated 9 December 2020, concerning death of Mr Thomas Rawnsley on 4 February 2015. Firstly, would like to express my deep condolences to Mr Rawnsley's family- Secondly, would like to apologise for the delay in response regulation 28 report concludes Mr Rawnsley's death was 'Natural Causes and that Mr Rawnsley died as a result of 1a: Global hypoxic-ischaemic encephalopathy 1b: Cardio-respiratory arrest Ic: Chest infection II: Down's Syndrome Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding Primary care are undertaking more and more virtual consultations with patients and the advice that is provided is inherently more risky over the phone with GPs not being in strong position to assess the patients understanding of the advice that been given in the same way as can when the patient is sitting in front of them in the practice. This advice is not followed up in writing and therefore it may be misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas; is having his care delivered by professional carers. (2) There is a standard set of questions asked by the call handler on a 111 or 999 call which is not then replicated for clinicians who subsequently triage a patient Without a standard set of initial questions asked it is entirely possible that clinicians will provide advice in isolation of other important matters: This could be NHS England and NHS Improvement Watery . the The has they

as simple as current medications that the patient routinely takes or current diagnosis patient has which impact upon the advice to be provided. This may lead to incomplete or worse, inappropriate advice being given to patients during a clinical Point 3 of the Regulation 28 would be more appropriately answered by the Yorkshire Ambulance Service. With regard to Point 1: NHS England and NHS Improvement (NHSEII) understands the Coroner's concerns raised around consultations which are not undertaken in person , and we are assured that there are both new and established procedures in place to ensure that this is a safe practice. These are also supported by published guidance and training, which aim to summarise below Telephone consultations have been in use in general practice for many decades to help patients access medical advice and care quickly and conveniently. Where studies have been conducted, telephone care has been shown to be safe_ Telephone consulting is included as part of the general practice curriculum and training to support safe and effective practice_ It is clear the use of virtual consultations with patients and the delivery of NHS services remotely has progressed significantly and continues to evolve. The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context: These procedures make it clear that general practices and Primary Care Networks should triage patients remotely (determine the right person and timeframe for managing problem) in advance wherever possible to help prioritise patient care based on needs; and that clinicians should determine the most appropriate consultation method with the patient telephone, video , online , face to face_ This should be determined by taking into consideration the patients preferences, needs (including accessibility, privacy, capacity and communication requirements) , clinical circumstances and currently, local risks of COVID-19. In determining the most appropriate consultation method, considerations regarding patient safety, ability to make satisfactory assessment; gain a sufficient understanding of the problem and whether information can be provided in a way the patient understands including assessing a patient's understanding of the advice provided should be factors in determining the most appropriate consultation method. Safety netting is a routine part of general practice consultations and explicitly sets out next steps to take for the patient in the event of a deterioration in their condition_ The importance of these principles is emphasised in joint guidance between the Royal College of General Practitioners (RCG)P and NHS EIl (link is included later in my response): If a particular concern did arise following a remote assessment or remote advice being given, then a decision could be made to move to an alternative approach, for example, face to face consultation or for remote advice to be followed up in writing or with the patient's permission with their carer_ the triage the

Based on the clinical circumstance and considerations outlined above, many clinicians have used SMS and online messaging services that are now available in general practice to follow up a remote consultation with patient with links to validated advice via NHS.UK, or attach information leaflets which patients can refer back to. Patients are also now able to request full access to their medical record which would enable them to refer back to previous consultations_ The approach used would be expected to be tailored to the circumstance and individual patient needs taking into account the risk of information being "misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas; is his care delivered by professional carers Professional guidance published by the General Medical Council sets out high level principles of good practice expected of everyone when consulting and or prescribing remotely from the patient: https IIwWW_qmc-Uk orglethical-quidancellearning materialsIremote-prescribing-high-level-principles Additionally, guidance has been developed jointly between NHS Ell and the Royal College of General Practitioners (RCGP) on Remote_vs Face_to Face which to Use and when?, Principles of safe_video consulting_in general practice during COVID 19 and RCGP Top 10 for COVID-19 telephone consultations_ AII these documents underline the importance of ensuring patient safety and that an individual's needs are paramount A further development since 2015 is the increased focus on improving how health services understand and respond to the needs of patients with learning disabilities and autism. The NHS EIl Long Term Plan highlights this as a priority and describes work undertaken to implement national learning disability improvement standards for all services funded by the NHS This includes, by 2023/24, a 'digital flag' in the patient record which will ensure staff know a patient has a learning disability or autism_ The use of this 'digital flag' should further enable consideration of the needs of patient with regard to virtual or remote consultation. In light of the above we consider it would be disproportionate to routinely require the provision of written follow up information following any and every remote consultation in primary care but that this should be based on clinical judgement: In respect of Point 2: Turning to recommendation on replicating the standard set of questions asked by 111 call handlers to clinicians subsequently involved, the current "standard set of questions" utilised in NHS 111 services is NHS Pathways. NHS Pathways is a series of questions, that assesses symptoms presented at the time of the call and identifies the appropriate next level of care. NHS Pathways triage is built around a clinical hierarchy, meaning that life- threatening symptoms are assessed at the start of the call; triggering ambulance responses as necessary and progressing through to less urgent symptoms that require a less urgent clinical endpoint (or disposition). having tips being the

Where a call is passed for further clinical assessment or consultation , all questions asked along with their response are shared with the receiving clinician to inform their subsequent assessment and decision-making_ If the case is subsequently passed to an NHS Pathways clinician , would validate the information that has been shared and where necessary probe further if required to undertake a full assessment. The process of validating the information the initial call and probing further as necessary provides clinicians with the basis from which to seek information on other important matters which may impact on the advice to be provided. Some cases will be passed to clinician within the Clinical Assessment Service (CAS) , this will include those clinicians who formerly worked in organisations known as 'out of hours providers. These clinicians work within their professional competences and training and will use the usual medical model to assess patients. These clinicians will be subject t regular audit normally using the RCGP Urgent and emerqency Care_Toolkit There is also increasingly better sharing of patient records between clinicians working in different settings. Under a change in regulations (CQPL Control of Patient Information) for the coronavirus (COVID-19) pandemic to additional information in the_summary care record andlor as part of a local shared care record GP OOH, NHS 111 and ambulance services are able to see, as a minimum, for direct care purposes, information such as details of long-term conditions, significant medical history, medications and allergies. In light of we consider that replicating the standard set of questions asked by 111 call handlers to clinicians subsequently involved, would not improve the process which is in place, as described above. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.