Dear Mr Shah Re: Report to Prevent Future Deaths: Ms Diana Gudgeon Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 9 January 2019, bringing to my attention HM Coroner's concerns arising from the inquest into the death of Ms Diana Gudgeon. I would like to assure you that matters related to patient safety are taken extremely seriously by the Trust. 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
1. Triaging by '111' and EMAS call handling systems, including in relation to sepsis. In the present case, Mrs Gudgeon had collapsed, passed out, been confused and had been vomiting. These are signs of central nervous system/neurological problems but were not regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract infection, no escalation occurred. Each individual call received by the Trust is either triaged via the Advanced Medical Priority Dispatch System (AMPDS), using the information provided to us either by the caller or is received via the electronic gateway from NHS Pathways - the 111 system. The AMPDS is an internationally recognised triage system that uses a data set to determine the response level required, based on the information provided during the call. The call is categorised at source, according to the information provided by the individual caller or the system. At this time there was no information provided by the caller that warranted an escalation of the call. Respond I Develop I Collaborate

When we re-contacted the patient at a later time, no additional information was provided and the call remained as the same category. If additional information had been provided to the call taker that triggered an escalation via AMPDS to a higher category, this would have escalated the call to a higher category.
2. It was suggested in evidence that if the same facts are inputted into the '999' AMPDS triaging system they are likely to allocate a higher priority to the call than the '111' Pathway triaging system would. Both AMPDS and NHS Pathways are advanced clinical triage systems designed to enable the call taker to process a 999 call based on information received from the caller and to arrive at a response priority. The two triage systems operate within different algorithms and with a different series of questions to ask the caller when prioritising the call. As each system has differing algorithms and different question sets, and each 999 call is managed as an individual call, there will be occasions where different priorities may be attributed to the same set of circumstances within each triage system. As an example, AMPDS ambulance trusts more often have a higher proportion of Category 2 999 calls than Trusts that use NHS Pathways.
3. The shortage of double crewed ambulances and fast response vehicles in the Northampton Division. A jointly commissioned, independent "demand and capacity review" identified a gap between the resources presently available, and what was needed to deliver national performance standards for ambulance services. In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m extra funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms. The funding will directly address the gap identified in the demand and capacity review, and is expected to result in a stepped improvement in the Trust' s ambulance response times and consistency of response across all areas of the East Midlands region. The additional money will be invested in the right level of resources to enable the Trust to respond more quickly and consistently to 999 calls and urgent GP requests and to achieve national standards at a county level, which came into force for all ambulance trusts in autumn 2017. Since the additional funding was announced and as at the end of February 2019, the Northamptonshire Division have recruited an extra 39 frontline staff and further staff are in Respond I Develop I Collaborate

the process of being recruited. 20 staff are now recruited, trained and operational. The remainder in training will commence training in the next quarter. To support the additional resources, we are also recruiting private providers with qualified staff.
4. The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, inter alia, the fact that:- a) CMP status 1- 3 does not trigger the deployment of additional vehicular resources. b) CMP 4 is only triggered when 200 calls are holding (this was previously 150) - this is a high threshold. c) A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding (CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander. We do look to move resources from one Division to another and therefore we have to balance against how many jobs are holding in each Division. On this occasion, it was unfortunately not possible to move any resources. The Trust's Capacity Management and Escalation Plan has been through a rigorous governance process and the triggers are regarded as a safe process for managing our demand. The Plan is reviewed on an annual basis. Given the complexity of the CMP I would like to suggest that a further, detailed explanation be presented to HM Coroner or representative. Alternatively we could arrange for a visit to our Emergency Operations Centre to see the CMP in place; we could also take the opportunity to illustrate the AMPDS triage system at this time. If you feel that this would be beneficial, Mrs Natalie Harrison, Coroner Services Manager, will be pleased to make the necessary arrangements. I hope that the measures set out in this letter provide you with the appropriate level of assurance in relation to our 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 Mr Shah Re: REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS DIANA GUDGEON write in response to your query raised regarding the 111 service as follows: Triaging by '111' and EMAS call handling systems, including in relation to sepsis. The patient had collapsed, passed out, been confused and had been vomiting: These are signs of central nervous system/neurological problems but were not regarded as urgent: Despite EMAS being told that the patient may have a urinary tract infection, no escalation occurred: Explanation as follows: The NHS 111 service and some 999 services, use NHS Pathways software which consists of algorithms developed nationally by the Royal Colleges of GP's, Paediatricians, Emergency Medicine, and Psychiatry etc_ All sites the software contribute to feedback on these algorithms and versions are updated twice yearly. We are using NHS Pathways version 16.0 at the present time which is the most up to date version: The call has been reviewed against NHS Pathways version 14, which was in use at the time of the call. The question relates to whether the patient was severely ill. The response from the son was unclear in answering this question_ The Health Advisor (who is trained in the use of NHS Pathways, but who is not a clinician) could have probed this question more appropriately by utilising the supporting clarification information within NHS Pathways in order to get a clearer answer to this question_ However, in order for this question to have been answered positively there is a second part to the question which asks whether the patient has new marks like bruising or bleeding under the skin: Both severely iIl and the new marks have to be present in order for this question to be answered positively_ Answering this question positively is the only way that the disposition of a Category 2 ambulance could have been reached. As the severely ill stem was answered negatively the stem asking about new marks was not asked, but no rash was mentioned on the call. We have reviewed the case and used the other presented symptoms such as a fall, vomiting and behaviour change and the highest disposition we could have reached is a Category 3 ambulance. DHU 111 (East Midlands CIC is a Limited Liability Company: Registered in England Number: 10259076 Registered Office: Johnson Building, Locomotive Way, Pride Park, Derby, DE24 8PU the SOCIAL EnteRPRISE MARK Toaniuc [nd Dcndi CaV[ 'gov. using key APPROVED)

high blood sugar test over 27.9mmol as opposed to the reported 16 mmol would only have triggered a Category 2 ambulance if the severely ill and new marks question had also been answered positively. Over the last year we have shared our concerns regarding NHS Pathways ability to pick up possible sepsis effectively and have fed our concerns back to them: This has resulted in changes to NHS Pathways in both versions 15 and 16. We have taken this call through NHS Pathways version 16 to try to identify the likely outcome had this version been in place at the time of the call: In version 16 the severely ill and new marks question has changed significantly. Firstly the 2 parts have now been split into separate questions_ Due to concerns that the severely ill part of the question was too subjective this has been altered to "so ill have stopped doing all normal activities" The new marks part of the question is separate and triggered by answering the so ill they have stopped all normal activities question positively_ The wording of the new marks part is unchanged. Having followed this call through version 16 of NHS Pathways Category 2 ambulance would only have been triggered if both the so ill have stopped doing normal activities and the new marks questions had been answered positively. In summary both the version of NHS Pathways in use at the time and the latest version would have required new marks to have been present in addition to the patient to have been severely ill in order for a Category 2 ambulance to have been triggered. We attach copies of the questions relating to severely iIl and marks in both NHS Pathways version 14 and 16 for your information However the wording of the questions in version 16 has improved and supports Health Advisors to answer the questions in a more straightforward manner. As the question was not asked we are unaware whether a rash was present. Category 3 ambulance dispositions have a target response time of 90% of calls reached with 120 minutes and a new target has been added of a mean response within hour We understand that EMAS have a policy of contacting patients at the point are likely to breach the 120 minute target to ensure there has been no change in the patient's condition_ We note that a clinician from EMAS did call around the time of the anticipated breach to assess the patient: We note that following this call no escalation occurred. Category 2 ambulance dispositions have a target response time of 18 minutes with 90% of calls to be reached within 40 minutes As part of the NHS pathways training, new Advisors cover sepsis as part of the Distance Learning Pack (DLP), see attached. The information within this pack is formally assessed by means of an exam paper which advisors have to achieve a pass rate of 70% and above to continue with the course. The Advisors cover scenarios in training which aid them with exploring the Pathways system, which include symptoms of sepsis. In addition to this, all Advisors attend Spotting the Sick Child training which covers NICE Guidance of feverish illness in under 5's and the sepsis risk stratification tool (see attached) The Clinicians all receive the Sepsis Risk stratification tools as part of their clinical training The Clinicians have all been notified of a free online course on Sepsis in Primary Care on the following website https IIWW e-lfh orgukl DHU 111 (East Midlands CIC is a Limited Liability Company: Registered in England Number: 10259076 Registered Office: Johnson Building, Locomotive Way, Pride Park, Derby, DE24 8PU THE SOCIAL ENTERPRISE MARK Toaninc cod dcndi aun GiNc very they doing they being they @PPROVED

do hope that the above explanation has addressed your concerns If however, there are any matters which are still outstanding or points which are unclear please do not hesitate to contact me via the Clinical Governance Department; at the above address or via the clinical governance e mail: DHULClinicalGovernance@nhs net or telephone 0300 1000 407