Emergency services related deaths

Noted (AI summary) The Welsh Ambulance Service explains why it carries naloxone but not flumazenil, stating that flumazenil is not safe for widespread use and that ambulance personnel are trained in more appropriate techniques for benzodiazepine overdose.

Noted (AI summary) NHS England explains the NHS Pathways triage system and how it handles repeat calls, noting that ambulance services have local procedures for managing duplicate callers, including a geofence and other differentiating factors. They also highlight the use of the 'what3words' function to support location identification. West Midlands Ambulance Service explains their call taking protocols, addressing how they manage duplicate/repeat calls and clarifies the circumstances surrounding the delayed ambulance response, attributing it to significant hospital handover delays. They state the ambulance crew initially went to the kidney treatment center because they were unaware Mr. Fray had returned home.

Noted (AI summary) NHS England expresses condolences and states that concerns have been listened to and reflected upon. They highlight the remit of other organisations (NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust) regarding some of the concerns, and reference workstreams to increase ambulance capacity and improvements to Tameside's ED. They also note the discussion of PFD reports by their Regulation 28 Working Group to share learnings.

Noted (AI summary) NHS England outlines actions taken to improve ambulance performance, including implementing the Delivery plan for recovering urgent and emergency care services, engaging with West Yorkshire ICB, and publishing the NHS Long Term Workforce Plan. These actions include joint escalation processes, investment in resources, and workforce enhancements. West Yorkshire ICB describes actions taken to reduce ambulance response times and handover delays, including funding for additional resource in call centres. The ICB also highlights the development of a System Coordination Centre (SCC) to enable a proactive system response to operational pressures. The DHSC acknowledges the concerns regarding ambulance response times and hospital handover delays, notes that West Yorkshire ICB and NHS England will respond directly on specific actions, and highlights national initiatives to improve urgent and emergency care performance.

Noted (AI summary) NHS England outlines key actions from their Delivery plan for recovering urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity, improving hospital flow, speeding up discharges, and expanding community services. They also mention the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The DHSC acknowledges concerns about ambulance response times and hospital handover delays, directing the coroner to NHS England and Birmingham Integrated Care Board for specific actions. They highlight the 'Delivery plan for recovering urgent and emergency care services' and funding allocated to boost ambulance capacity and improve patient flow. NHS Birmingham and Solihull outline several actions to address ambulance delays, including the implementation of a medical push model, improvement activities to reduce length of stay, and a single transfer of care hub. These measures aim to improve patient flow out of acute hospitals.

Noted (AI summary) NWAS has reviewed the use of NHS Pathways for overdose calls, implementing an automatic prompt for an advanced questionnaire if 'risk of suicide' or 'accidental poisoning' is recognised, leading to an automatic upgrade to Category 2 for patients who have taken higher-risk medications. Clinicians in the Clinical Navigation, CSD, and CCD teams have undergone extended training and will use TOXBASE to support decision-making. The Minister acknowledges the concerns raised and explains that national guidance is in place for ambulance services regarding overdose calls, including clinical intervention within 30 minutes or automatic upgrade to Category 2. NWAS is best placed to respond on specific local actions.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance response times, refers to the NWAS response, and highlights the 'Delivery plan for recovering urgent and emergency care services' and related initiatives.

Noted (AI summary) NHS Sussex investigated the concerns raised with the GP practice and reviewed information for technology sharing of patient’s GP records and found that the Practice had systems in place to enable other healthcare professionals to remotely access the GP records. Further enquiries of SECAmb may be needed to understand their systems, processes and their understanding of what is available to them in order to fully address HM Coroners concerns.

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) Skills for Care recommends that every frontline care worker within a CQC regulated service should receive First Aid training, including basic life support as part of their initial induction to the sector, and ensure these skills are regularly refreshed. They highlight existing guidance and initiatives, but note that they cannot mandate training. Peabody has improved its training program for care workers in supported living environments, now requiring certified First Aid and Basic Life Support training before solo work. Existing care workers will also complete the new course within one year and the organisation has launched an Ofsted-registered Academy. CQC acknowledges the regulation regarding staffing qualifications and training and highlights that Peabody has revised protocols to ensure no support worker lone works without enhanced training in emergency first aid and basic life support, and is ensuring appropriately trained personnel on every shift. CQC will be considering the case under its framework for health and safety incidents.

Noted (AI summary) NEAS will undertake a review of the triage process and NHS Pathways questions, focusing on call re-categorisation. They are finalising a business case for commissioners to consider, which would support the introduction of a Critical Incident Hub to increase the number of dispatch officers. The Department acknowledges the concerns regarding the NHS Pathways system and the pressures on ambulance services. It highlights improvements in ambulance response times and ongoing efforts to boost ambulance capacity, but describes no specific changes to policy or procedures related to the concerns raised.