Emergency services related deaths

Noted (AI summary) NHS England explains the NHS Pathways Clinical Decision Support System and how it is used. They state the exit scripts are for local determination and cancellation of ambulances is outside the remit of the NHS Pathways system. The Department acknowledges concerns about ambulance response times and call handler scripts, and states that NHS England is addressing the script issue. The government highlights its Plan for Change and upcoming 10-Year Health Plan with reforms and investment, and promises to set out improvements to urgent and emergency care by Spring.

Noted (AI summary) NHS England detailed several actions taken to address the coroner's concerns, including: implementing a 'Complex Call' process to ensure clinicians assist health advisors with medication/medical related triaging, and providing 'Hot Topics' learning materials regarding Addison's disease. The Department of Health and Social Care acknowledges the coroner's concerns regarding the NHS Pathways system and patient information sharing, noting that NHS England is responding to the specific concerns raised.

Noted (AI summary) The Welsh Ambulance Services University NHS Trust acknowledges concerns about ambulance delays and the MPDS system but states it is not the primary authority to take action, offering to meet to discuss the response in more detail and welcomes suggestions for actions they might take with partners.

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) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.

Noted (AI summary) NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group.

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.