Emergency services related deaths

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.

Noted (AI summary) The North East Ambulance Service details their procedures for checking doors and alternative transport options, noting that welfare calls are prioritized for patients who are alone.

Noted (AI summary) NHS England outlines existing guidance for ambulance services relating to overdoses and suicidal intent issued in April 2021, and describes ongoing work to improve ambulance performance. North West Fire Control is supporting the embedding of Joint Emergency Services Interoperability Principles (JESIP) and working with partners to implement electronic data transfer for improved information sharing, expected by March 2024. Cheshire Constabulary has signed the Joint Operating Protocol (JOP) with NWAS and supports its endorsement by other parties, with a coordination meeting scheduled for January 16, 2024. Lancashire and South Cumbria ICB reports that four North West police forces have agreed and gone live with their Joint Operating Protocols (JOPs) with NWAS, with Greater Manchester Police in the final stages of agreement, and learning will be overseen by the NWAS Regional Clinical Quality Assurance Committee. Cumbria Constabulary has signed a regional Information Sharing Agreement (ISA) and has been working under a Joint Operating Procedure (JOP) since October 2023; it also provides clinical support through its "treat and hear" facility. Lancashire Fire and Rescue Service states that it was not involved in the incident, but is committed to improvement and learning. The service outlines its support for JESIP, reviews policies/procedures/training, and has an Immediate Emergency Care SOP with guidance on various areas. Four of the North West police forces, including Cheshire Constabulary and Merseyside Police, have agreed and implemented Joint Operating Protocols (JOPs) with the North West Ambulance Service to improve information sharing and escalation processes. The North West Ambulance Service (NWAS) have engaged with all the North West Police Forces to develop a Joint Operating Protocol (JOP). Four forces have agreed and gone live with their JOPs, ensuring clear process for sharing information, primacy understanding, and a clear escalation process for any operational issues. BTP has adopted the "Ten Second Triage" (TST) tool nationally and is delivering associated training in 2024. They also use ESICTRL radio talk groups for direct communication between emergency service control rooms. NWAS reports that a Joint Operating Protocol (JOP) has gone live with Cheshire, Cumbria, Lancashire and Merseyside Police Forces, and that an updated version has been agreed with Greater Manchester Police and is scheduled for implementation across the whole North West following a meeting in late February 2024; also, the JOP has been extended to include British Transport Police, North West Fire Control, and Fire and Rescue Services. Merseyside Fire and Rescue Service states that its existing procedures for communicating casualty information to NWAS are sufficient, including written instructions and escalation options. Lancashire Police has agreed to Version 1.3 of a Joint Operating Protocol (JOP) with regional forces and NWAS to provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays; awaiting final sign-off from GMP and Fire and Rescue. Response not parsable

Noted (AI summary) NHS England explains the NHS Pathways system and its governance, noting that NHS Pathways is owned by DHSC and that all reports received are discussed by the Regulation 28 Working Group.

Noted (AI summary) Welsh Ambulance Services NHS Trust does not propose further action directly, but is working with Aneurin Bevan University Health Board to implement additional measures in January 2024 to reduce conveyances to The Grange Hospital through direct admission to alternative sites, and the introduction of a new temporary facility. They also offer to meet to discuss the response in more detail. The Health Board acknowledges handover delays and that an ACA2 crewed ambulance could have attended. It states that reducing patient handovers is a focus and that the Chief Operating Officer and Clinical Executives are providing leadership to address the issue. NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat cover the diagnosis and early management of relevant symptoms, and they have not been asked to produce specific guidance on Group A streptococcus.

Noted (AI summary) West Midlands Ambulance Service acknowledged the ECG was abnormal and that policy wasn't followed; clinicians received a case review, participated in a Serious Incident process, completed reflective practice, and are scheduled for additional ECG/ACS training. Additional actions include updating policies and providing additional equipment/training to improve chest pain management and ECG interpretation. The Health and Care Professions Council acknowledges the concern but states that the individual in question is not registered with them, so the concerns do not fall within their remit for further investigation, but the individual's name has been added to a watchlist. The Health Services Safety Investigations Body is undertaking exploratory work regarding paramedic interpretation of ECGs in the community and will consider the scope for a formal investigation by the end of January 2024. The University of Wolverhampton will present case evidence to students, incorporate ECG interpretation into Objective Structured Clinical Examinations, liaise with coronary care units for anonymised ECG readings, add an ECG interpretation workbook to the virtual learning environment, and organise continuing professional development ECG masterclasses. The CQC has reviewed WMAS's actions following the death and found no evidence of provider-level failings, although they identified concerns regarding the timeliness of addressing the training needs of staff involved. The training needs of one staff member have been addressed, and the second staff member's training will be met upon their return to work.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and outlines actions being taken by NHS England and EEAST to improve ambulance response times, including increased recruitment, clinical triage of calls, and the establishment of an Unscheduled Care Coordination Hub.