Dear Mrs Connor,

Inquest reference the death of Sally Perrons Regulation 28 Report- Action to prevent Future Deaths

Thank you for granting us an extension to Sept 1st to respond in full to the concerns you raised following the tragic death of Sally Perrons. I am pleased to advise that I am now in a position to appraise you of the actions that the National Ambulance Sector has agreed to take in response to those concerns.

As you know our work has involved liaising with and canvassing each of the ten English Ambulance Trusts together with the Welsh Ambulance Service. This work has been facilitated by AACE but led by the National Medical Directors Group (NASMED) chaired by

In order to respond to your concerns we undertook a comprehensive survey of the current position of ambulance trusts in relation to intubation and capnography. The questionnaire was prepared and sent to Medical Directors and Lead Paramedics of Ambulance Services in England and Wales. It was also sent to the devolved administrations of Scotland, Northern Ireland and Republic of Ireland and replies were received from them to give a fuller overview of current practice.

The results of this survey established that there is variation in the training and re-assessment of paramedics in the skill and practice of intubation. It found differences and recognised issues around monitoring intubation practice and variation and availability of devices for end tidal carbon dioxide monitoring.

The results of the survey were used to discuss your concerns more comprehensively in the National Ambulance Service Medical Directors Group and agree on a number of actions in response to your concerns which are detailed below.

Your concern:

Point 1: The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.

Our actions:

 Development  of  a  national  recognised  teaching  standard  for  the  stepwise  airway  management and ventilation.   This will include airway positioning, simple adjuncts and advanced techniques which include supraglottic devices and paramedic intubation. This standard will describe how a paramedic will be initially trained and deemed competent to practice the skill of intubation. This action to be completed by July 2015.

 Development within all services of a common individual paramedic skills log, which  will record airway manoeuvres, use of supraglottic airway devices and intubations as a  minimum.  This could be further developed to include a log of cardiac arrest management, major trauma care and use of other advanced interventions such as intraosseous needle placement and chest decompression. This action to be completed by July 2015.

 Annual  re‐assessment  of  the  individual  paramedic’s  advanced  airway  skills  will  be  based on the airway log, taking into account the number of times advanced airway  skills such as intubation were performed and a review of any problems encountered.  Authority to continue intubation will also be part of the assessment based on whether  any airway management problems have arisen.  This action to be completed by July 2016.

Your concerns:

Point 2: Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.

Point 3: Availability of these devices to staff, and training on how to use and interpret them.

Our actions:

 Confirmation of endotracheal tube placement will now include detection of EtCO2 This  will be mandatory for every intubation with immediate effect and initially will require  the  use  of  either  a  digital  ETC02  monitoring  device  or  the  use  of  full  waveform  capnography. Paramedics will not be allowed to intubate patients where this equipment  is not available to them and will need to manage the airway using alternative airway  adjuncts.   This action to be completed with immediate effect.

 The use of waveform capnography will be considered the gold standard but given that it  will take up to three years time to procure this expensive equipment and train staff in its  use this objective will take longer to achieve. We are however committed to having all  this in place on every responding vehicle crewed by a paramedic as soon as is practically  possible.  This action to be completed by July 2017.

Your concern:

Point 4: In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.

 Each individual service will consider whether they continue in the future to teach intubation as a core skill or whether to restrict it to specialised and advanced paramedics. The survey did establish that two ambulance services have already decided that new graduate paramedics will not be practicing intubation in their Trusts.

I hope that you will agree that we have dealt comprehensively with the concerns that you have raised. It has required a great deal of co-ordination between ambulance trusts who have shown themselves to be absolutely committed to learning from this tragic event and doing everything within our power to prevent it happening again in the future. In addition AACE and NASMED will keep progress against these recommendations under regular review and take appropriate action as required to ensure they stay on track.