Emergency services related deaths

Noted (AI summary) The First Minister for Wales acknowledges concerns about ambulance patient handover delays at Cwm Taf Morgannwg University Health Board and outlines the Welsh Government's governance and escalation processes for NHS organisations, noting that all health boards are in escalation for urgent and emergency care.

Noted (AI summary) NHS England acknowledges the concerns about the NHS Pathways algorithm and details its function. It highlights existing access to clinical support for health advisors and refers to work by the Regulation 28 Working Group. The practice has amended its process for new baby registrations, including removing the 'unregistered babies' folder and updating the Docman system to allow electronic rejection of incorrectly sent correspondence. The trust has already taken several actions including auditing the call, sharing learning through various channels, and providing training to staff. They have also reviewed and amended the NHS Pathways cardiac arrest algorithms following a previous case. The CQC contacted the provider, Unity Health, who confirmed they reviewed their processes and implemented a new system for creating a new profile when they are notified about a birth. They flagged this issue with the ICB and will be sharing details of this incident with the CQC’s Primary Care inspection teams.

Noted (AI summary) The Welsh Government outlines its role in setting the strategic context for health services and holding NHS organisations accountable, noting that all health boards are in escalation for urgent and emergency care. They mention providing additional funding to Betsi Cadwaladr University Health Board and supporting improvement programs, but do not commit to specific changes in response to the report.

Noted (AI summary) Durham Constabulary's Deputy Chief Constable states that a full review of the case and police actions was undertaken, with the outcome and actions attached to the response. The Police and Crime Commissioner expressed condolences and noted that a review by Durham Constabulary didn't highlight significant failings but resulted in two points of organisational learning and recommendations. The commissioner will monitor the 'Right Care Right Person' model. The College of Policing has contacted Durham Constabulary, who have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. Durham Constabulary will implement recommendations aligned with the National Toolkit for Right Care, Right Person (RCRP), aiming for full implementation by mid-July 2025. These include a review of police systems for further intelligence, supervisor review, and immediate escalation to the Supervisor on a second call about the same person within a 12 hour period.

Noted (AI summary) NHS England describes the NHS Pathways triage tool and its capabilities, particularly for patients unable to move. They explain the triage hierarchy, the system's functionality since 2018, and the role of local protocols. They also mention a working group that discusses reports to prevent future deaths. South Central Ambulance Service has created a directive to staff including changes to triage processes, such as ascertaining if the patient is alone, requesting contact information, using a minimum Category 3 response for patients slipping from furniture, documenting patient position, referring cases to a clinician, and ensuring cases are not closed without an appropriate response. The directive was approved and will be issued this month.

Noted (AI summary) NHS England acknowledges concerns about the use of NHS Pathways to triage mental health situations, notes it has already considered management of callers at risk of suicide, and will keep the clinical content under review. It also notes that the triage system elicited the correct information triggering the approved ambulance response.

Noted (AI summary) South Central Ambulance Service details actions taken since December 2023 including introducing the "Fit for the Future" programme, increasing paramedic apprenticeship numbers, reviewing skill levels of crews, increasing support for newly qualified paramedics, utilising specialist practitioners, implementing a new joint process with healthcare partners regarding ambulance crew wait times at hospitals and updating their fleet of vehicles. BT clarifies its procedures for handling emergency calls, including operator actions, listening practices, and the Critical Call Process, and explains that distress alone is not an agreed trigger for the Critical Control Process.

Noted (AI summary) The North East Ambulance Service emphasizes existing training and education for paramedics on stroke symptoms, including the possibility of symptoms dissipating, and highlights the strengthening of their Senior Clinical Leadership team. The General Chiropractic Council has established an expert group to review the coroner's findings and recommend actions to prevent similar deaths or harm to patients, with a final report expected by October 2025. The chiropractor states they will continue to follow the rules and guidance issued by their regulator (GCC) and looks forward to receiving any updated guidance from the GCC. The General Chiropractic Council established an Expert Group, comprised of members from within and outside of the profession, to consider the coroner's findings which resulted in an Action Plan with practical solutions for chiropractors to incorporate into their daily practice. The British Chiropractic Association held webinars to refresh the knowledge of their members on the symptoms and treatment of stroke and the Royal College of Chiropractors initiated work to review their emergency referral form.