Emergency services related deaths

Action Planned (AI summary) NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system.

Action Planned (AI summary) The Trust has implemented measures to improve ambulance turnaround times, including daily meetings to review patient flow, screens displaying ambulance information, purchasing additional trolleys, and having Ambulance Liaison Officers on site during high demand. The Trust also joined a Phase 2 NWAS ambulance handover collaborative project. Blackpool CCG emphasized a Roster Review in commissioner requirements and are involved in initiatives to improve hospital handover times by using improvement methodology with several hospitals. They are also part of a North West Handover Improvement Board. NWAS is trialing a pilot program in the Cheshire and Mersey EOC to manage meal breaks differently, involving a mandatory staggered stand down of resources. They will also be adding 250 paramedics to the service by March 2020. The Department of Health and Social Care outlined actions to improve ambulance services, including implementing an improved ambulance performance framework, issuing revised hospital handover guidelines, and improving monitoring and reporting of patient handover delays. They also made the AACE aware of the coroner's concerns.

Action Planned (AI summary) West Midlands Police has reviewed its call handling procedures, including providing additional training, instituting a "Log Closure Doctrine", reducing the number of logs held by each dispatcher, changing the dispatch model and shift patterns. They are also developing a new Command and Control platform to support call handlers. The Home Office will ask officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. The Home Office states that public safety remains the government's number one priority and cites increased police funding and plans to increase officer numbers. West Midlands Police accepted that the 101 call was incorrectly graded and has discussed this with the staff member in question, and has promised additional training for all control room staff. They have also instituted a "Log Closure Doctrine", reduced the number of logs held by each dispatcher, changed the dispatch model and shift patterns, and are developing a new Command and Control platform.

Action Planned (AI summary) AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission.

Action Planned (AI summary) EMAS has issued bulletins to frontline staff and control centers clarifying procedures for safe discharge of lower acuity calls, mental capacity assessments for patients refusing transport, and CAT access to patient history and records. All staff have access to the EMAS Safeguarding Policy and procedures. AACE will request that JRCALC review UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management, and will ensure that any recommendations are published.

Action Planned (AI summary) The MPS will review the roles and responsibilities of the police pursuits pod to ensure they are maximising information/intelligence opportunities. They will consider a mandatory checklist of indices at the start of a pursuit and ensure Pan London courses and refresher training include an input on information and intelligence gathering. This review will be completed by 31st October 2019.

Action Planned (AI summary) The Trust acknowledged a paramedic's lack of awareness regarding Rivaroxaban and is implementing an action plan for individual learning and organizational changes. They will ensure all clinical staff are aware of the effects of Novel Oral Anti-coagulant drugs.

Action Planned (AI summary) NHS Pathways is undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage process, including utilizing risk factors and specific questions to determine the onset and nature of pain. Changes will be incorporated into release 18 (due for deployment 7th October 2019). South East Coast Ambulance Service has discussed the coroner's concerns with NHS Pathways, who are reviewing care instructions and considering amendments to the Pathways script for inclusion in version 18 or 19, due for release in Autumn 2019. NHS Pathways will review the inclusion of additional questions to exclude abdominal aortic aneurysm as part of a review into severe abdominal pain.

Action Planned (AI summary) South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of call handler training. The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary of the issue to be circulated to heads of contact management across England and Wales.

Action Planned (AI summary) EMAS acknowledges exceeding response times and states that additional funding was agreed to address this. The funding will be used for clinical staff, ambulances, and other resources to improve response times and consistency across the East Midlands.

Action Planned (AI summary) South East Coast Ambulance Service is working with commissioners in a jointly commissioned demand and capacity review, intended to better align resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards. The recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring.