Dear Mr Brown Inquest into the death of Kyle_Lowes (Deceased) Regulation 28 Report to Prevent Future_Deaths We write in response to your Regulation 28 Report to Prevent Future Deaths dated 26 August 2016, following the Inquest into the death of Kyle Lowes, which was held on 16 and 17 August 2016 at Berwick upon Tweed Coroners Court. We were not invited to attend or provide you with evidence in respect of the commissioning of ambulance services, and would have valued the opportunity to provide this information to you and the family in advance of your decision to issue a Regulation 28 Report. You addressed the report to NHS Northumberland Clinical Commissioning Group (Northumberland CCG) because you were informed at the Inquest that we enable, commission or fund the provision of the services and that the North East Ambulance Service (NEAS) stated in evidence that are dependent upon the services being commissioned: Northumberland CCG is currently one of four nominated lead CCGs who actively participate in commissioning and contracting of ambulance services on behalf of all 10 CCGs in the north east region. The four lead CCGs represent both rural and urban areas ensuring the challenges across these diverse geographies are discussed and population needs are considered when contracting for services_ Through quality standards and continual performance management, commissioners work closely with NEAS to ensure the dynamic deployment of resources can be adapted to meet the changing demands on them as a service We do not however dictate the operational decisions made as to the deployment of resources Enabling NEAS the freedom to deploy resources across the county and the north east within the parameters of quality requirements ensures the provider; who is best placed to understand the demands, takes the most appropriate action when necessary: For example NEAS has stated that an additional rapid OISABLEQ Tony they ABOUT TIVE 1

OFFICIAL SENSITIVE PERSONAL response vehicle resource will be allocated to north Northumberland from December 2016. This will be provided within current funds and will enhance the resource to this rural area and improve performance times to our rural population Whilst some elements of ambulance activity are increasing, there has been a 2.1% decrease in total ambulance activity since 2013. The activity profile in Northumberland sees more requests from general practice and health care professionals and less red calls than other CCG areas, this relates to general practice and community services visiting more patients at home and providing services across the rural geography of the county_ There has been an increase in the numbers of red life threatening calls for ambulances (category red and 2) , and commissioners have made a conscious decision to increase the overall expenditure on ambulance services and commit to supporting their transformation programme_ The contract with NEAS is a block contract; offering financial stability for both provider and commissioners over a two year period whilst multiple initiatives and service transformation projects are progressed. The contract covers all emergency, urgent and planned patient transport as well as national contingency services such as the Hazardous Area Response Team, Medical Emergency Response Incident Team and encompasses the regional emergency planning and the National Intensive Care Bed Information Service_ NEAS has reported an impact on their workforce and resources due to a shortage in emergency care paramedics To mitigate this they have developed transformation projects to ensure the service can meet current and future demands but to also ensure patients can reach the appropriate care at the right time. These projects are supported by the CCGs and form part of the wider urgent and emergency care service developments across the north east. The transformation projects include: Increased emergency care workforce planning_ Enhanced front line clinical management: Utilising contract income to increase capacity to compensate for staff vacancies with third party resource Participation in the national ambulance response programme pilot. Trial to use Fire and Rescue services as first responders_ Increased clinical advice capacity within the call centre Paramedic clinical hub. More locally Northumberland CCG has required NEAS to work closely with Northumbria Healthcare NHS Foundation Trust (NCHFT) to plan for the challenge of the new ways of working at the new Northumbria Specialist Emergency Care Hospital (NSECH) in Cramlington: In an attempt to mitigate the impact of the operational change to where patients access care, the CCG has sought assurance by specifying that: Given the location of the county and its border with Scotland, NEAS developed protocols to ensure their crews remain in England and more specifically in Northumberland when clinically appropriate

OFFICIAL SENSITIVE PERSONAL Continued joint working between NEAS and the Scottish Ambulance Service to provide vital cover if a NEAS resource isn't available to respond to a life threatening call:. Regional agreement to a divert policy to ensure patients are transferred to the nearest hospital and ensure treatment is administered within appropriate time frames where there are known delays at some hospital A&E departments_ Northumberland CCG recognises there is further action required to improve the ambulance handover processes at the NSECH and has commissioned the national Emergency Care Intensive Support Team (ECIST) to undertake a root cause analysis and improvement plan to address all issues_ This work is due to commence in the coming weeks_ The CCG has worked with all provider partners to establish the local A&E delivery Board, Chaired by the Chief Executive of NHCFT, which will oversee the outcomes from the ECIST input to ensure all providers in Northumberland do what is required to deliver safe and effective services to the population: This is a continuation of the system resilience network established over the previous two years. With the aim of addressing overall capacity, and to join up services, the CCG is working with NHCFT, NEAS GP surgeries and community nursing services to review the services _in Alnwick and Berwick to ensure all health care professionals are used appropriately. This means that providers share staff and their skills to treat patients most effectively and efficiently. This includes an agreement between NEAS and Northumberland CCG that, where needed, in order to fill significant gaps in service provision or to attend to life-threatening emergencies when there is no closer paramedic vehicle, community paramedics will be moved out of their designated area in order to assist: This will be on an exceptional basis, and the community paramedics will remain based within their local rural areas This review aims to align with NEAS' plans to introduce an Advanced Paramedic Practitioner supporting rural crews and avoiding unnecessary journeys to the NSECH but also building community base care and networks with local GPs, the hospitals services, community and out of hours providers. Northumberland CCG also welcomes the intention of NEAS to deploy an additional Rapid Response Paramedic in the north of the county, increasing the resource to respond to emergency calls, from December 2016. The CCG acknowledges the concerns of the coroner with regards to provision of services in rural areas across the north east including Berwick and north Northumberland and wish to stress that as commissioners it will ensure NEAS and all partner providers do all within their power recognising the issues discussed within this letter; to deliver a safe service to the population of rural Northumberland and across the north east as a whole.