Dear HM Senior Coroner Pollard Re: Inquest into the untimely death of Christopher Philip Fields Date& Time of hearing: Monday 11th April to Thursday 14th April 2016 Location: Stockport Coroners Court Matter: PFD Regulation 28 Report Thank you for your letter dated 19 May 2016 which encloses a copy ofthe Regulation 28 report issued against NWAS, pursuant to paragraph 7, Schedule 5 of the Coroner s and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013. note your specific concerns centre around the following: '2. The calls (999) to the ambulance service were properly coded and applied by the call taker leading to a Green 2 response: This should have led to the vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes: Why was the response time so dramatically lengthier than prescribed and is this @ matter of resources? (NWAS)
3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly criticolly injured and despite that fact it still did not generate & Red response, suggests that the algorithms used for coding are not accurate and not fitfor the purpose. In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied: (NWAS, SECRETARY OF STATE and NHS ENGLAND): Taking each point in turn, confirm that the vehicle response time for the incident in question, was inextricably linked to the activity pressures, NWAS faced during this extremely challenging winter period. Despite winter weather contingency planning activity within the Greater Manchester area saw an unexpected 22% increase, which was directly compounded by significant hospital turnaround pressures faced at Stepping Hill, North Manchester and Oldham Headquarters: Ladybridge Hall, 398 Chorley New Road, Bolton. BL1 SDD

The wider NHS reported similar pressures and it is recorded that Yorkshire Ambulance Service declared a Major incident at 14.30 due to the volume of work faced on the date in question; It should be noted that Green 2 response times are 'as soon aS practicable' and whilst NWAS strives to attend these types of incidents as soon as practicable, due to the challenges faced on the date in question, the response time was regrettably longer than we would have hoped; NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which hope will assist in alleviating some of these pressures. In regards to AMPDS system, | confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient's chest had been 'concaved in' this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response note that the attending police officers evidence supported that the patient was breathing; conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patients condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment) Furthermore this assertion was reinforced byE IPathologist report which supported that the critical injury was sustained during the second assault: you will accept that these are difficult issues to resolve, with no quick fix solutions, but continued efforts are being made to consider better ways of managing these challenging periods. Ifyou do have any further concerns or questions please feel free to contact me: Kind regards Head Of Services they hope very Legal

From lhe Lord Prior of Bramplon Parliamentary Under Secrelary of Slale for NHS Produclvlty (Lords) Department of Health Richmond House Mr JS Pollerd 79 Whitehall Senior Coroner London SWIA 2NS Coroner'$ Court 1 Mount Tabor Street Tel: 020 7210 4850 Stockport SKI 3AG 13 JUL 2016 lalJ Thank you for your letter of 19 2016, following the inquest into the death of Christopher Fields I was sorry to hear of Mr Field's death and wish to extend my condolences to his family. Iam aware that the North West Ambulance Service has already responded to your concerns and I have seen & copy of the reply. However; You are also concerned that the call to the ambulance service did not generate a red code response time (between 8 and 19 minutes) when the patient was critically injured. You consider that this was because the algorithms used by the call handlers for coding calls are neither accurate nor fit for purpose and ifnot remedied; could lead to future deaths You ask that the Department of Health responds to this concem: NWAS has confirmed that the emergency call concerning Mr Fields was correctly_ coded as & Green 2 based on the priority symptoms reported, which at the time of the call were not critical. The critical injuries to which you refer were sustained following a second assault some two hours after the first: Had critical injuries been reported the first emergency call, different algorithm questions would have been asked by the call handler and the call would have been coded with a higher response category: NWAS use the Advanced Medical Priority Dispatch System (AMPDS) for handling 999 emergency calls. This system determines the priority in which vehicles should be dispatched based upon the immediacy of the life threatening symptoms displayed by the patient; a5 reported by the caller: The call handler then assigns a code for the call which maps to one of the following response categories below: May during ~

Category A calls (ife threatening): Red 1 - 8 minutes: Respond to 75% of Red ] calls within 8 minutes with a suitably trained and equipped response. This could be an ambulance, a Rapid Response Vehicle or a community responder Red 2 - 8 minutes: Respond to 75% of Red 2 calls within 8 minutes with a suitably trained and equipped response. This could be an ambulance, a Rapid Response Vehicle Or a community responder A19: Respond to 95% of Category A (red 1 & 2 combined) calls within 19 minutes with vehicle capable of carrying a patient. Green calls (serious but non- lilfe threatening): Green ] and 2 - face to face ambulance response within 20 minutes (95% of the time): Green calls (non-life threateningon-emergency): Green 3 - Telephone assessment within 60 minutes (100% of the time) alternative pathway referral, upgrade to RedlGreen or 2, advice given and call closed. Green 4 Telephone assessment within 60 minutes (]00% of the time)- alternative pathway referral, upgrade to Red/Green 1 or 2, advice given and call closed or a vehicle response within 4 hours I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case: However; please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concems about the design of tbe product you may wish to contact them direct at the following address: Priority Dispatch Corporation UK Limited Suite B, 4th Floor Spectrum Bond Street Bristol BST 3LG Ihope that this reply is helpful ad I am grateful to you for bringing the circumstances ofMr Field's death to my attention. Yus L DAVID PRIOR

Dear Ms Kearsley Re: Christopher Philip Fields (deceased) With regards to the report sent by letter from HMC Mr Pollard dated 18 May 2016 in respect of Christopher Philip Fields pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph Schedule 5 of the Coroner's and Justice Act 2009. apologise for the delay in responding as this correspondence was not received into my office until 16 June 2016. reply to the matters you have asked me to consider as follows; Extract from Regulation 28_point 1 The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window; which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurances, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death_ Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner why did not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc Why did leave an injured andlor intoxicated person in the sole care of another who was also intoxicated why did consider it appropriate to accept the view of the injured / intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (NDMM) The NDMM allows officers to make decisions based on the following principles: Gather information and intelligence Assess threat and risk and develop a working strategy Consider powers and policy Identify options and contingencies Take action and review what happened Both gave evidence at the Inquest and provided their rationale with reference to the National Decision Making Model (NDMM) They assessed that Mr Fields did not lack capacity to make decisions, was talking calmly and coherently and making his own choices. Mr Fields wanted the police officers to leave and had (who officers believed were his friends) with him. He was not giving the officers any information which would allow them to Postal address Greater Manchester Police , Openshaw Complex, Lawton Street Openshaw; Manchester M11 2NS Poni they they they

Contd page 2._ progress their investigation. Mr Fields had the telephone number for Stockport Homes and was capable of speaking to them to speed up the joiner if necessary: A crime report was recorded at the time in line with national crime recording standards and the officers carried out a primary investigation: The officers had assessed that although Mr Fields had minor visible injuries they were not serious or life threatening, however they did feel that he still needed to be assessed by medical professional ad an ambulance was still required. Following all of this, judged that there was no policing purpose to justify remaining at the scene. The officers were interviewed by the said that she believed that the risk to Mr Fields would be minimised if he had friends with and "if had any indication at all that were a threat to Christopher would have stayed with him" The officers stated that were influenced by Mr Fields stating that he was "fine" in the presence of the two persons_ The IPCC investigator's opinion was that both made appropriate dynamic assessments about the extent to which Mr Fields had any welfare needs and required safeguarding, based on his injuries, his ability to meet his own needs and his behaviour whilst in the company of and The officers also based their assessment on Mr Field's limited response to their questions and him wanting the officers to leave the flat. was spoken to by the officers as potential witness and had given conflicting accounts She initially denied any knowledge of the incident; had confronted her with information that female had been seen running away, and she told the officer that she had called for the ambulance, but did not know who was responsible Mr Fields as the victim, was taken to one side away from the two persons present in the address and spoken to privately, being asked what had occurred, who was involved and if he wanted the other two people removing: Mr Fields told the officers that they could remain as were all friends The crime and incident recording procedure states that the investigation should be victim focused: Appendix D of the Incident Response policy states that the victim's needs and the investigation must be at the forefront of all decisions A check on previous incidents at the address would not have assisted with any decision to arrest, as there was long history of alcohol related incidents involving Mr Fields and other persons_ The IPCC noted that neither officer challenged_ account or actions; she said she was asleep at the flat at the time of the assault but Mr Flelds was adamant no women had been at his flat, also state that the officers missed the opportunity to ask was actually to at least establish his identity in light of the information from the house to house witness. However; the officers checked Ifor signs of injury or bloodstains on his clothing and found none, to which HMC acknowledged this as "the officers took the precaution of checking the knuckles of and satisfied themselves that there was no evidence of injury such as might be expected from someone who had recently been involved in a fight" . asked the male who presented as if he might in fact be which was denied Moreover, the police were told repeatedly by Mr Fields that was not the person who had assaulted him, and that he was his friend: Both officers gave clear, unambiguous evidence that they did not consider to have been the perpetrator, and in such circumstances there would be no grounds for an arrest The Police and Criminal Evidence Act 1984, requires for a lawful arrest when there are reasonable grounds for suspecting person's involvement or attempted involvement in the commission of a criminal Postal address Grealer Manchester Police, Openshaw Complex Lawton Street Openshaw Manchester M11 ZNS him, they they They

Contd page 3.._ offence and reasonable grounds for believing that the person's arrest is necessary. On the information available to the officers at the time, there was insufficient evidence of involvement in a criminal offence by ay of those present at the scene: This was also accepted by HMC, summing up find that there was insufficient evidence upon which the officers could reasonably be expected to have arrested the mar In relation to the learning that has arisen out of this case, was given management action for the lack of documentation within his pocket note book Errors in recording inaccurate information was addressed in the witness evidence of Operational Communications Branch Business Lead at Inquest: It is proposed that we will be able to report back to the Coroners_ In October 2016 in terms of the wider work we are completing around vulnerability, including the lessons learnt from this case

Dear Ms Kearsley, Re: Regulation 28 _ Christopher Philip Fields refer to the Coroner's Regulation 28 Report concerning the death of Christopher Philip Fields and would like to express my deep sympathy to Mr Fields' family. The Report outlined three concerns with only the following point identified as being potentially relevant to NHS England: 3 The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact it still did not generate a Red response, suggests that algorithms used for coding are not accurate and not fit for purpose. In my view this is an extremely serious fiaw and maylill lead to future deaths occurring unless it is remedied: (NWAS, Secretary of State, NHS England): note the response from North West Ambulance Service (NWAS) , letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time: It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist's report: NWAS useS the Advanced Medical Priority Dispatch System (AMPDS); an internationally recognised system developed and accredited by the International Academies of Emergency Dispatch, and tested on many millions of 999 calls in the United Kingdom and overseas. Whilst AMPDS is generally regarded as fit for purpose, it can never be 100% accurate because it relies heavily on the accuracy of the information supplied by a caller, and to a lesser extent on the interpretation of ambulance call handling and dispatch staff. The Coroner may appreciate that these human elements are vulnerable to individual error. NHS England is currently leading complete review of ambulance coding systems and trialling a new system. This review will take into account both the High quality care for all, now and for future generations RECEIVED SEP

outcome of previous similar 999 calls as well as the concerns raised by Coroners in Regulation 28 Reports. We anticipate making recommendations in autumn
2016. It is our intention that this review should improve the service provided and clinical outcomes for future patients contacting the 999 ambulance service. Thank you for bringing this matter to my attention: