Dear Mrs Brown Re: Report to Prevent Future Deaths: Mr Graham Smith write in response to the Regulation 28 Report to Prevent Future Deaths, which you issued on 23 May 2019, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Mr Graham Smith. would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, matters arising from Coroners' Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed within the Incident Review Group and Lessons Learned Group. Coroner's Concerns It became apparent during the course of the Inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behaviour, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or "red flag" warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed. "- •w • t. - •• • .•~

It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there maybe good working models already achieving this aim, or parallels maybe considered with sudden frequent attendances of patients to ED.
1. CAD alerts EMAS currently has a process in .place to alert all Emergency Operations Centre (EOC) staff upon receipt of a call, that a previous call has been made from that same address, or within 50 meters of the address coordinates, within the last nine hours. This is highlighted by a yellow warning box stating "Possible Duplicate Calls" on the Computer Aided Dispatch (CAD) system. Having received this notification, the dispatcher will check the CAD system and verbally notify the crew by radio of any previous attendance within the last nine hours. In Mr Smith's case, however, the previous attendance was outside of this window, which at that time was only five hours. We are incrementally increasing this time to twelve hours; however we have to do this in small increments to ensure that it does not have a detrimental impact on the CAD system. We are currently reviewing our CAD system to address the feasibility of having enhanced duplicate call checking to see if this five-hour window can be extended for a period of up to 12 hours. However, we will need assurance that this will not impact on the overall performance of the system, as this could have a detrimental effect on our ability to respond to incoming ca I Is.
2. Information given to clinicians can confirm that all crews on all attendances to Mr Smith were provided with information regarding the presenting condition of Mr Smith. This information was passed to the crews by the Dispatchers via the Mobile Data Terminal system (MDT), which is located on the dashboard of the ambulance. Our system confirms that these messages were read by the crews on the ambulances which attended Mr Smith.
3. Patient assessment on scene We would expect any crew attending a patient to undertake a holistic assessment of the patient, including taking a history of events leading up to that attendance.
4. Non-Conveyance Leaflet 2

When a patient declines transport to hospital or the crew feels that hospital attendance is not indicated, the crew should leave anon-conveyance leaflet with the patient. This leaflet includes the date and time of attendance and the observations recorded and an overview of the attendance. In the event that a crew attends subsequently, or a patient subsequently attends their GP Surgery, the patient should present the leaflet to the attending clinician. EMAS On Scene Conveyance and Referral Procedure -Non-Conveyance Guide Please find attached to this letter two clinical bulletins issued by the EMAS Medical Director reference Supported Safe Discharge of Care for Technicians and Newly Qualified Paramedics that clarifies the calls that can be discharged at scene safely. These bulletins have been issued to all frontline clinical staff and Emergency Operational Control centres for clarification. This permits Technicians to safely discharge lower acuity calls themselves, however, they must seek clinical support or advice when considering discharging a higher priority call. Refusal to travel — If a patient refuses transport to hospital; the attending Technician should carry out a mental capacity assessment on the patient and then contact the CAT who will speak to the patient and ensure that the refusal is made on a recorded telephone line. The patient's signature should be gained on the Electronic Patient Report Form stating that they are refusing transport to hospital, as per the Non-Conveyance Summary Guide for Technicians. The CAT team has had access to all previous calls and attendances for the past three months. The team also has access to summary care records (which are an electronic record of important patient information, created from GP medical records) and in Leicester, read-only access to SystmOne (a centrally hosted clinical computer system used by GPs and other healthcare professionals in the UK). This enables the CAT clinician to be fully informed of the patient's past medical history and any care plans which may be in place, enabling them to make an informed decision as to whether the patient requires onward referral or whether the patient can safely be left at home.

6. Safeguarding of patients In addition to the above, all EMAS staff have access to the EMAS Safeguarding Policy and procedures and can access a variety of supportive pathways for patients. hope that the measures set out in this letter provide you with the appropriate level of assurance in relation to EMAS' commitment to continuous improvement of services. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above.

Dear Mrs Brown

REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS: GRAHAM GEORGE SMITH

I am writing further to your Regulation 28 report to prevent future deaths which you issued to the Chair of JRCALC following the inquest into the death of Graham Smith.

You requested that JRCALC consider matters of concern and suggested that action is taken to prevent future deaths. Your matters of concern were:

‘No guidance in relation to alcohol withdrawal symptoms and its potential complications, in relation to fluctuating capacity, awareness of symptoms, a patient’s ability to make decisions and understand information.’

JRCALC is a group of specialty experts and its role is to provide robust clinical specialty advice on the instruction of the Association of Ambulance Chief Executives (AACE) and its advisors, the National Ambulance Service Medical Directors (NASMeD). It is AACE and its advisors NASMeD that are providing this response to you.

AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts who are all full voting members. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Its 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 it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines.

We will be taking action to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management. We will ensure that any recommendations are published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.

I hope that you will agree that we have responded to the concerns that you have raised and explained our reasoning. I can assure you that we are absolutely committed to learning from all such adverse events and doing everything within our power to prevent them happening again in the future.