Dear Dr Griffin, Thank you for your letter dated 17th November regarding your Regulation 28 report to Prevent Future Deaths Kathryn Verina Richmond_ Within your letter the area of concern you have raised is as follows: Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts, there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time therefore request that a review is undertaken of the guidance given t0 Ambulance Service Trusts regarding the structuring of their rota system to stagger shifts which in turn will stagger meal breaks to ensure as many resources possible are available at any one time: In preparing our response we have also been in contact with South Western Ambulance Service (SWAST) and have reviewed their response to your concerns and the actions they have taken internally to address those concerns_ Clearly there were two main issues in this tragic incident the first involving the way in which the incident was managed internally by the SWAST Emergency Control Centre and secondly the availability of ambulances associated with crews being on protected meal breaks These issues have been addressed internally by SWAST as part of their response to this incident: Whilst you have indicated that you are satisfied that lessons have been learned in SWAST and changes have been made which adequately address your concerns you remained concerned that similar issues could occur in other Ambulance Trusts nationally. Firstly , can be clear that the Association of Ambulance Chief Executives (AACE) has no power to mandate Ambulance Trusts nationally to make changes to their operating practices which remain a matter for individual trusts and their respective Boards That said AACE can and does act as a national co-ordinating voice on many issues of policy and practice and importantly collates information on serious untoward incidents and the lessons learned from them: We maintain a database of such incidents and share outcomes from them widely with the National Ambulance Medical Directors Group (NASMeD) and the National Chairman: Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE

Directors of Operations Group (NDOG): This is to ensure that learning within an individual Trust which might have national implications is shared across all Trusts allowing action to be taken where necessary to avoid similar incidents occurring: This is always done when a Coroner issues a Regulation 28 report: Turning to your areas of concern we will ensure that the lessons learned and the actions taken by SWAST are incorporated into our national database of Regulation 28 reports and that both groups take on board the learning from the incident: The changes which SWAST have made in the way in which managed the emergency call may have been specific to SWAST we will ensure that those issues and the subsequent changes are shared nationally to allow other Trusts to review their procedures internally to satisfy themselves that their internal control room processes are satisfactory_ In terms of the staggering of meal breaks all ambulance services are aware of the need to do this as much as possible and regularly review their rostering systems to stagger start and finish times and hence their meal break 'windows'_ There is a balance to strike which needs to give Trusts the to allow emergency crews to have a meal break which they are legally and morally entitled to in order to protect their health and well-being whilst at the same time safeguarding emergency cover to ensure appropriate response times for patients. In addition, all ambulance trusts have the ability to ask crews to interrupt their meal break to attend patients who are life threatened and whilst this is a voluntary system it will have been agreed locally in each case with ambulance staff and their trade unions. In my experience, this works well and dedicated ambulance staff will invariably interrupt meal break to respond to such patients_ The Department of Health and NHS England do not issue specific guidance to ambulance Trusts on the structure of their rostering systems or their meal break arrangements. These remain a matter for individual Trusts to negotiate locally. That said, all Trusts are aware of their responsibilities in this area and regularly review those arrangements to ensure are robust and are optimised to meet current demand patterns_ AACE will ensure that the National Directors of Operations Group (NDOG) is made aware of your concerns associated with this tragic incident and remind them of the need to ensure that this is done on a regular basis. hope you will agree that this addresses the areas of concern that you have raised: