Dear Ms Connor Re: Report to Prevent Future Deaths: Peter Scott (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11" May 2016, bringing to my attention the Coroner's concerns arising from the inquest into the death of Peter Scott 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, any matters arising from Coroners Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group having considered all the relevant issues of concern relating to the particular inquest will develop an appropriate action plan with specified timelines and identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Death notice pertaining to the inquest into the death of Peter Scott. The MATTERS OF CONCERN are as follows: consider) that there is risk of future deaths as set out above unless an urgent review of resources is undertaken. Consideration should be given to strategies to improve handover times at hospitals Taking the concerns in turn, set out the actions we have taken and our response to HM Coroner's concerns in the PFD notice. The Care Quality Commission report recognised that EMAS has been working really hard to improve response times to emergency calls. However there are concerns that ultimately relate to the lack of resource (staff and vehicles) made worse by the numbers often kept waiting at hospital; and lack of capacity to do things as quickly or as well as should be. they

East Midlands Ambulance Service [NHS NHS Trust Emergency Care | Urgent Care We Care EMAS has taken the CQC seriously and value the additional support from other NHS organisations following the CQC Quality Summit: With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS' immediate control. Following extensive negotiations an agreement has been reached with all commissioners for the EMAS 2016/17 Accident and Emergency 999 contract: The final position is for a one year block contract with a value of E152.5 million: key part of this year's contract is the agreement to carry out a independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service_ EMAS and clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand. Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against recruitment plan target of 342- However, higher level of turnover was experienced compared to that forecast (11% against target of 8%). EMAS continues to recruit to the frontline again this year: Through exit interviews, EMAS monitors the reason for staff leaving: From those interviews the top reasons are (in order of priority): Lack of opportunitylcareer progression/further 2 Work life balance 3_ Better pay To address this, EMAS has produced a new People Strategy to develop and support our staff to be highly skilled, motivated, caring and compassionate professionals_ Hospital handover is the time it takes Emergency Department staff to accept clinical handover from ambulance crews, thereby releasing them to respond to other 999 calls (Note: national target for this is 15 minutes). Hospitals are not able to accept prompt clinical handover when are experiencing high demand or a large influx of patients arriving at the same time. The Care Quality Commission inspection at EMAS in November 2015 and findings published in May 2016 brought focus to the seriousness of the hospital handover delays experienced over the last year: Delays result in patients waiting on the back of ambulances, or in hospital corridors whilst their care is supervised by ambulance crews. While the ambulance supervision is being provided it prevents crews being able to respond to new 999 calls that have been received: This means patients in the community experience in response and this is of concern The delays impact on staff wellbeing and morale because can increase shift length and increase anxiety levels when crews know calls are waiting to be responded to, or when know will be first on scene having to explain lengthy delay: also impact on ambulance resourcing across the region, as vehicles and crews move across county boundaries to assist where there are delaysThis takes crews away from their usual operating area and has corresponding impact on the ability for the ambulance service to use resources efficiently. That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation. Actions taken by EMAS in particular at the LRI includes: findings the training they from delay they they they They

East Midlands Ambulance Service [NHST NHS Trust Emergency Care Urgent Care We Care Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce Increased number of paramedics based at hospitals to support their teams with the triage of patients and through the department A new booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when are being experienced These measures have allowed progress and improvements to the average handover times; however there is still more work to do to ensure the improvements continue on a sustainable basis, and that there is a continued reduction in long waits_ would also like to make a comment with particular regard to the work that EMAS has undertaken with the acute hospitals in Nottinghamshire_ Prior to March 2016 EMAS used Radio Frequency Identity (RFID) system to record the hospital handover time cycle. The system required a small tag to be attached to the ambulance stretcher and the electronic patient report form Toughbook: When either device passed through the doors at Queens Medical Centre (QMC), Nottingham a record was generated which allowed for monthly statistics to be produced: RFID proved difficult to manage as the device had to be matched to vehicle, should the stretcher or Toughbook be swapped onto another vehicle, the produced data could be erroneous. The data provided was not real time therefore delays could not be challenged at the time. Since March 2016 the QMC has engaged with EMAS t0 install Ambulance arrival screens_ Unlike RFID which used electronic the ambulance arrivals screen uses a simple touchscreen interface based on webpage. This new process provides real time data to both QMC and EMAS which allows both to see as happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete_ The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon: Illustration of QMC Arrival Screen chormange Notify Handover Curent Current Curreni East Midlands Ambulance Service Arrived t0 Handover Usage Usage Mumarou Ambulance Arrivals (Today) (Tocay) Hendover to Clear Averagt Averace Averace Queens Medical Centre Campus Hospital
73.33 % 97 7006 13 mins 10 mins
22.25 mi Total Resources Awalting Handover Creuss Anved cers Inbcund-; creus Expecteds us UpdJted: 15 2 Arrived call Number Callsign Type Call ReccNel As Stats TmevETA| Elpsd Pals Ratlllty Ashi 8375429 8411 EMG 21003 Dangerous Haemorrhage Notified
15.20 Emergency Dept 8375274 8916 EMG 30B01 Traumatic Injures to Possibly Dangerous Body Area Notified
15.06 Emergency Dept 8375239 8420 EMG DXO162 Transport t0 ED wlin Handover
15.07 Emergency Dept Inbound Call Number ' Callsigh TyPe call Recenved As Status Time/ETA Elpsd Pals Raclllty Ashif 8375407 8913 EMG 33[FT Priority IFT transfer Inbound 0 Mil Mins Emcrgency Dept 8375376 8419 EMG 31C01 Unconscious or Fainting Alertewith Abnoral Brea Inbound 3 Mil 6 mins Emergency Dept 8375425 2412 EMG 18C01 Headeche and Not Alert Inbound 3 Mi Mins Emergency Dept When are identified the Division will, where possible, allocate a Team Leader manager to act as a local Hospital Ambulance Liaison Officer (HALO): The role is to work with the hospital management team to ensure that ambulances are not delayed at hospital any more than necessary: delays flow delays tags delays they delays

East Midlands Ambulance Service NHS NHS Trust Emergency Care Urgent Care We Care The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time: Since April 2015 Nottinghamshire Division has increased available hours for both Double Crewed Ambulance (DCA) and solo Fast Response Vehicles (FRV): This is through the recruitment of staff and realignment of rosters to match increased demand_ Table Resourcing comparison April 2015 and April 2016 DCA Filled Hours FRV Filled Hours April 2015 34252 8606 April 2016 36487 9478 Increase 2235 872 Percentage Increase
6.52%
10.13% trust that this has answered all of the issues from your Prevention of Future Deaths Notice, but please do not hesitate to contact me if there is further information which is required

Dear Ms Connor

Regulation 28: Report to Prevent Future Deaths in the case of Peter Scott

This letter sets out the response of NHS Hardwick Clinical Commissioning Group (CCG) to your regulation 28 report dated 26th May 2016. You have raised the following point:

1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken

I would like to assure you that Hardwick CCG, on behalf of the 22 CCGs across the East Midlands region, works closely with East Midlands Ambulance Service (EMAS) NHS Trust to ensure that they have sufficient resources to respond to patients in a timely manner.

Response

1. There is a risk of future deaths as set out above unless an urgent review of resources is undertaken

Within the 2016/17 emergency ambulance contract CCGs have committed to undertake a jointly commissioned external strategic review focussing on capacity and demand in order to support delivery of an efficient ambulance service delivering performance across the region, with the outputs from the review being implemented over a three year period.

There are a number of key outcomes expected from the strategic review:

 An accurate analysis of current demand and capacity taking into account the issues identified within the recent CQC notice  An analysis in relation to current operational efficiencies covering, but not limited to, skill mix, fleet configuration and current delivery model  Identify the resource implications in terms of overall staffing and vehicles in order to deliver against national performance targets. This analysis would also determine any increases in staffing required to maintain performance and will detail the required front-line operational roles, and quantities, to operate the model.

Chairman: Dr Steve Lloyd Chief Officer: Andy Gregory

As part of the 2016/17 emergency ambulance contract settlement, Commissioners have provided additional funding to support EMAS to undertake further recruitment to increase their front-line establishment in order to ensure resources are available to respond to emergencies in a timely manner. The contract agreed is a block contract, which gives a year of financial certainty in relation to income, to give EMAS the confidence and ability to implement the necessary changes to delivering a timely response to all patients across the East Midlands.

The additional funding has enabled an expansion of the Clinical Assessment Team (CAT) who can provide clinical support and telephone assessment to support the management of patients through Hear & Treat where appropriate, thus releasing that resource to respond to patients with more serious clinical need that require immediate treatment or transport.

The additional funding will also support an increase in the numbers of front-line staff, thus increasing the resource available to respond to patients who require a face to face response.

Commissioners are actively working with EMAS and acute providers to reduce the number of patients who are waiting to have pre-clinical handover, thus releasing crews to be available to respond to other emergencies who require an ambulance response.

I trust this response addresses the point you have raised but I will be happy to discuss this further should you require.

Dear Ms Connor; Regulation 28: Report to prevent future deaths concerning the death of Peter Scott Thank you for your Section 28 report concerning the death of Mr Peter Scott. would like to express to the Scott family my deep sympathy and sadness at the death of Mr Scott_ Your report references the need to review the resources available to the East Midlands Ambulance Service NHS Trust ("EMAS"), and to consider strategies to improve handover times at hospitals_ NHS England would like to make the following observations in response to the specific concerns you have raised at Section 5: 1_ The need for an urgent review of resources to reduce the risk of future deaths The need to review the resources available to EMAS has been recognised locally _ The responsible commissioners, NHS Hardwick Clinical Commissioning Group ("CCG") on behalf of 22 CCGs across the East Midlands, have committed to jointly undertake an external strategic review of capacity and demand with EMAS. The review, which was agreed as part of the 2016/17 contract between EMAS and CCG commissioners, will consider a wide range of issues including the current delivery model, staffing issues and vehicle numbers. It is expected that the strategic review will provide an accurate analysis of the current demand and capacity issues facing the service, and will address many of the findings of the recent Care Quality Commission ("CQC") Quality Report into services provided by EMAS (published
2016). The 2016/17 contract settlement also provided additional funding to EMAS in order to increase front-line staffing with the intention of improving ambulance response times. It is also intended that services should be further improved by an agreed expansion of the existing Clinical Assessment Team ("CAT") as High quality care for all, now and for future generations May

treat greater proportion of patients safely without conveying them to hospital. This will free up both ambulance service and emergency department resources_ trust that this response addresses the concerns you have raised. am grateful to you for bringing these matters to my attention: know that the commissioners of the service (the CCGs) and the regulator of the Trust (NHS Improvement) are working closely with the EMAS to help them to bring about further improvements_

Dear Mrs Connor

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

I refer to your email of 26 May in which you enclosed a Prevention of Future Deaths Report you issued following the death of Mr Peter Scott.

I was very sorry to learn of the death of Mr Scott and the circumstances that led to it. NHS Improvement takes cases such as these very seriously and I would like to offer you the assurance that we are already working with the East Midlands Ambulance Service NHS Trust and other partner organisations to address the issue of resourcing and to improve response times to emergency calls.

You may be aware that the Care Quality Commission published a report on 10 May 2016 which recognised that the trust has been working really hard to improve response times to emergency calls, however the report highlighted concerns that ultimately relate to the lack of resource, both staff and vehicles. The trust has already been taking steps to address the resourcing concerns. In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.

Wellington House 133-155 Waterloo Road London SE1 8UG

T: 020 3747 0000 E: nhsi.enquiries@nhs.net W: improvement.nhs.uk

NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.

In the Annex attached to this letter, I have set out the steps the trust is taking and continues to take in addressing the resourcing shortage and improving response times to emergency calls.