Association of Ambulance Chief Executives

Noted (AI summary) • All officers—regular and Special Constabulary—now receive the same level of training in relation to ABD. • ABD training has been moved from the First Aid Learning Programme refresher sessions into the College of Policing’s Scenario-Based Training programme.

Noted (AI summary) NHS Birmingham and Solihull acknowledges the concerns raised and will work with Black Country ICB to coordinate a single response. The ICB takes the recommendations seriously and is committed to support Black Country ICB and WMAS in delivering necessary improvements. West Midlands Ambulance Service has implemented several actions, including face-to-face mandatory refresher training for breech birth in 2026-2027, resumption of the e-PROMPT course, a Trust focus on learning and improvement of obstetric emergencies, and removal of out-of-date WMAS Maternity Action Cards from all Trust Vehicles. They have also issued a clinical notice to all staff to remove and destroy the out-of-date cards. AACE acknowledges the concerns and explains its role in providing advisory guidelines (JRCALC) for ambulance services. While AACE is not responsible for training, it has shared the report with relevant networks for consideration, noting variations in paramedic training for maternity care and breech birth.

Noted (AI summary) NHS England has asked ambulance trusts to confirm compliance with NHSE guidance and has escalated the issue with the 25-C codes to the International Academies for Emergency Dispatch for rapid resolution. AACE states that the primary ownership of the concerns regarding 999 call categorisation lies with NHS England and that they have liaised with NHS England to ensure the matters of concern are being considered.

Noted (AI summary) NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National Primary Care Team will consider GP awareness of alerting ambulance services to specific conditions; the ICB will take the circumstances surrounding Margaret’s death to their GP learning sessions and consider a system-wide safety alert. AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient addresses. NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, and accepting care plans and flags from providers until an automated solution is available. They have also established an ICB-wide group to improve flagging challenges.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns raised and has forwarded them to NHS England, who are working with the Association of Ambulance Chief Executives (AACE) to review the concerns. AACE is consulting with expert advisors, obstetricians, midwives, and NHS England to review and update JRCALC guidance on maternal emergencies, including conveyance of patients when delivery is not progressing, with updates expected in approximately three months.

Noted (AI summary) Mid and South Essex NHS Foundation Trust has shared learning with teams about the JRCALC protocol on managing severe asthma in children and is delivering training sessions focusing on the role of Adrenaline; they have also sent an email to staff regarding the use of Adrenaline in pre-hospital asthma resuscitation. The Ambulance Service has disseminated posters addressing human factors, developed a new training package on decision-making under pressure, and is providing regular updates on best practice for asthma management. They have removed the skill of intubation for general paramedics and are rolling out Advanced Paramedics in Critical Care cars across the region. They have also implemented the Patient Safety Improvement Response Framework. AACE will review the JRCALC asthma guideline and make changes if required, and will share the concerns with their national ambulance service medical directors’ group (NASMeD) to consider further education or awareness for clinicians regarding airway management and adrenaline administration. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. The Department acknowledges the concerns and describes the existing framework for healthcare professional training, including the National Capabilities Framework for Professionals who care for Children and Young People with Asthma. They note that employers are responsible for ensuring staff are trained to the required standards.

Noted (AI summary) NICE acknowledges the concerns and notes that its new guideline on adrenal insufficiency covers identification, emergency management, and prevention of adrenal crisis during physiological stress, including trauma. The guideline committee includes paramedic co-optees and other relevant health professionals. NHS England reports that the JRCALC guidelines will be amended to improve understanding of administering steroids in cases of trauma, and that a Regulation 28 Working Group discusses all PFD reports to identify emerging trends. WMAS highlighted existing JRCALC guidance updates regarding steroid usage for adrenal crisis (2017, 2020, 2022), communication to staff via clinical times briefings, and the introduction of steroid emergency cards. WMAS also apologized for an administrative error that led to the lead investigator not receiving the inquest disclosure bundle and stated that the legal team aims to attend as many inquests as possible. AACE is revising JRCALC guidance to emphasize steroid administration to patients suffering trauma or physiological stress, engaging with the Addison's Disease Self-Help Group and The Addison's Clinical Advisory Panel Chair. AACE is also aware of the development of an educational e-learning package for call handlers to improve understanding of Addison's disease and steroid-dependent patients, which will be trialled in Yorkshire and potentially rolled out to other ambulance services. Worcestershire Acute Hospitals NHS Trust has amended its guideline to include clear advice for all patients in the Emergency Department requiring admission, delivered teaching sessions to surgical trainees and T&O junior doctors, shared a lesson of the week, and made changes to ED admission documents to include prompts on time-critical medications. The Society for Endocrinology highlights existing resources and the NICE guideline in development, commits to reviewing resources once NICE guidelines are written and ensuring pre-hospital care is covered more clearly, and is liaising with ambulance services to ensure triage information includes the need to send a category 2 ambulance.

Noted (AI summary) ENA has asked each DNO and TNO member company to check that emergency services have contact details and know how to respond to incidents; ENA will open dialogue with the HSE to see whether it can support them to further enhance awareness and will review and update its safety leaflet - Safety advice for the Emergency Services. NHS Digital explains the function and governance of NHS Pathways, noting that standard operating procedures and contact numbers are the remit of local service providers and do not fall under NHS Pathways' responsibility. AACE shared South Central Ambulance Service NHS Trust's updated SOPs, including a map and contact details for electricity Distribution Network Operators, across all NHS ambulance services. They are also discussing the matter with all Heads of Emergency Operations Centres. HSE shared concerns with the Care Quality Commission (CQC) and Healthcare Inspectorate Wales (HIW), the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee, and the Energy Networks Association (ENA), who have requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis; the ENA is currently reviewing their information leaflet on Safety Advice for the Emergency Services.

Noted (AI summary) EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used.

Noted (AI summary) NHS England will continue to work with HEE, the professional Royal Colleges, and other organizations to stay updated on new guidance and resources for managing severe allergies, and will explore using communication routes or commissioning levers to support their adoption. They also describe their assurance role for CCGs and commissioning of healthcare services. Advanced states they will work with NHS Digital to develop a standard for electronic updating of ambulance systems to inform them when an ambulance has been recalled. They also suggest an independent review of clinical triage systems. NICE notes that the British National Formulary (BNF) and BNF for Children (BNFc) already contain detailed advice on adrenaline auto-injectors, including MHRA/CHM advice from 2017 and 2019. It will consider how best to make clear in CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at all times. The Winchmore Hill Practice undertook an audit of patients prescribed Emerade to ensure dosage was in accordance with the BNF, reviewed AAI pen doses, and contacted patients with up-to-date advice from the MHRA. The practice has shared learning with the CCG medicine management team and amended the message on scriptswitch; any proposed changes to be made by CCG Pharmacist, will need to be approved by a Senior doctor at the practice. NHS Digital details changes made to NHS Pathways following the incident, including improving the Anaphylaxis algorithm, developing an audit framework, and conducting a user satisfaction survey to improve call-handling and call prioritisation. Bausch & Lomb distributes trainer pens to allergy clinics and is currently reviewing the design of its trainer pens to incorporate a needle cover shield extension when activated, to more closely replicate the patient experience with the actual pen. LAS clarifies the division of responsibilities for triage systems, stating that ECPAG and NHS Digital are responsible for setting categories and addressing inconsistencies between systems. LAS will discuss the PFD report at relevant user groups. The Department of Health and Social Care notes several actions, including the FSA working to get emerging trend information and alert local authorities, and working to identify means of access to relevant datasets so they can be included for analysis of food-related cases of anaphylaxis. The Healthcare Safety Investigation Branch (HSIB) will consider the matters of concern in the report and whether these meet its criteria for national investigation when the situation allows. Enfield CCG distributed a Medicines Safety Bulletin on Adrenaline Auto Injectors (AAIs) to GPs and other primary care healthcare professionals on 30th January 2020 and has contacted all GP practices. They are implementing a post-incident review and a report will be completed to ensure all actions identified are implemented to prevent a recurrence, including a review of governance processes and decision-making points.

Noted (AI summary) The Association of Ambulance Chief Executives (AACE) outlines the triage process for 999 calls, the role of the Emergency Call Prioritisation Advisory Group (ECPAG), and references a letter sent to ambulance trusts in April 2019 from NHS England regarding clinical oversight for self-harm and suicidal patients. NASMeD previously encouraged all ambulance trusts to implement clinical review of these cases.

Noted (AI summary) The College of Policing and NPCC are working with forces and medical service partners to address concerns related to Acute Behavioural Disturbance, including raising awareness and consistency in recognition and response. The Chair of the NPCC will write to all Chief Constables to bring the content of the PFD to their attention. The Department of Health and Social Care acknowledges the report but states that a response will be delayed due to an upcoming General Election. They will contact the office to agree on a new deadline once a new administration is in place. Joint guidance between ambulance services and police forces is in development, overseen by a joint committee. AACE will share operational considerations with the National Directors of Operations Group (NDOG) for ambulance services, and will discuss the report at future meetings. St John Ambulance is providing additional Continuous Professional Development training around Acute Behavioural Disturbance. They have also raised the topic for inclusion in the latest version of the First Aid Manual.