Emergency services related deaths

Noted (AI summary) The Welsh Ambulance Services NHS Trust acknowledges the coroner's concerns regarding the effect of long lies and systemic pressures. The Trust highlights collaborative work and limitations in insisting on discrete actions beyond lobbying and emphasizing patient safety concerns, while also recognizing the need for systemic change and support from the Welsh Government.

Noted (AI summary) The Nursing and Midwifery Council outlines existing standards and processes related to DNACPR understanding and fitness to practise, without describing new actions taken or planned. Avalon Nursing Home updated DNACPR and RESPECT forms in care plans, discussed clinical judgements with a local surgery and paramedics, provided refresher training in basic life support and first aid, and amended its policy on calling an ambulance and DNACPR.

Noted (AI summary) NHS England and NHS Improvement are writing to ambulance services regarding clinical oversight, including a reminder that Acute Behavioural Disturbance (ABD) calls should have oversight of a senior clinician in the control room and calls should be upgraded to Category 1 if the patient’s condition deteriorates or if the patient is being restrained. The Association of Ambulance Chief Executives (AACE) explains its role and states that it cannot mandate response categories. AACE developed and issued national clinical guidance in 2019, updated in 2020, to UK ambulance clinicians, supported education and presented at conferences and webinars for police and ambulance staff, and continues to develop further guidance around managing patients with extreme agitation. The College of Paramedics clarifies it is not responsible for setting standards for paramedic education, training, or practice, but will ensure its pre-registration curricula review includes the latest evidence on Acute Behavioural Disturbance. The College endorses AACE's response and will share the correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose a review of the current response categorisation of Acute Behavioural Disturbance. NHS Digital provides background information on NHS Pathways, a clinical decision support system used by NHS 111 and some ambulance services, and its governance structure. It states that NHS Pathways is concordant with NICE, the UK Resuscitation Council, and the UK Sepsis Trust guidelines.

Noted (AI summary) NHS England reiterates national policy on 15-minute ambulance handover times and highlights actions taken to address delays, including alternative patient pathways, improved hospital flow, and additional funding for Hospital Ambulance Liaison Officer staff. On 13 December, NHS England and NHS Improvement reiterated the need to eliminate ambulance handover delays. University Hospitals of North Midlands NHS Trust (UHNM) highlights measures to reduce ambulance delays including a focus on patient flow, admission avoidance, and improved discharge processes. They developed a Standard Operating Procedure (SOP) to manage ambulance arrivals when there is a necessity to hold WMAS crew and patients on ambulances. UHNM considers this a system-wide issue requiring a system response.

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) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.

Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.

Noted (AI summary) NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve information sharing and mental health services.