Caroline Pilkington

WS WwIlBI Wiel
age 15 MAY 2014 From the Rt Hon Jeremy Hunt MP

Secretary of State for Health

Department
of H ealth Richmond House
79 Whitehall
London
POC1_ 851396 SWIA 2NS
Tel: 020 7210 3000
Ms M J Leeming Mb-sofs@dh.gsi.gov.uk
Senior Coroner
HM Coroner's Court
Paderborn House
Howell Croft North
Bolton
BL1 1QY

Des Ms bani,

Thank you for your letter following the inquest into the death of Caroline Louise
Pilkington. In your report you conclude that the medical cause of death was
accidental, caused by Propranalol toxicity.

On 25 April 2013, Miss Pilkington was found suffering from a fit in an upstairs
bedroom at her home address. The North West Ambulance Service (NWAS) was
called and three paramedics attended. Due to the violence of Miss Pilkington’s
movements in the course of her fit it was necessary to restrain her limbs in order to
remove her safely from her home. NWAS personnel called the police service to
assist them. Officers of Greater Manchester Police attended, applied restraints to
Miss Pilkington and assisted in removing her safely from her home.

Miss Pilkington died on 26 April 2013 at Royal Bolton Hospital. She had taken an
accidental overdose of Propranolol which had been prescribed some time before for
pain relief.

You raise the following concerns:

¢ NWAS personnel are not trained in control and restraint techniques. This
results in them having to call the police service to assist them when
dealing with ill patients who require control and restraint.

e This is so despite the fact that other clinical personnel, for example Mental
Health nurses, are trained in such techniques.

e In this case the three paramedics had to call for assistance from the police
service. The police, although trained in control and restraint techniques,
are not clinically trained to deal with such patients.

e The involvement of the police service in these cases not only potentially
results in inappropriate removal of police officers from their core policing
duties, but also potentially results in harm to patients being caused by
delaying their removal to hospital.

You have found that these matters did not cause or contribute to Miss
Pilkington’s death. However, you believe there is a risk that future deaths would
occur while ambulance personnel remain untrained in control and restraint
techniques, partly because police staff are not clinically trained and partly due to
delays in taking patients to hospital whilst awaiting the arrival of the police.

I note that you sent a copy of your report to NWAS and IJ am aware of the
contents of their reply. They have advised you that:

A joint protocol was developed between the North West Region Police Forces
and NWAS in March 2012 which supports inter-agency working and the
appropriate use of shared resources to deliver the best possible care for patients
who lack capacity. All five police forces in the North West have agreed to the
protocol.

The protocol means that NWAS staff may request police assistance for patients
in need of emergency treatment who lack capacity and who require restraint due
to threatening or violent behaviour towards themselves or others. The police will
respond to the incident as an emergency and the ambulance staff and police
officer(s) will then work together and agree a plan on how to manage the patient
in the safest, timeliest and least restrictive means possible.

Both the police and ambulance service employ highly skilled, well trained and
specialised staff who each have a vital role to play in the care and safety of the
public. NWAS believe that this model of collaborative multi-agency working is
the best way to achieve consistency and guarantee safety for patients.

The use of restraint and reasonable force is supported under the Mental
Capacity Act 2005 (MCA), to ensure that patients lacking capacity receive
appropriate care. Although NWAS staff are trained to provide minimal restraint
in cases where patients lack capacity and there is no perceived risk of harm to
them or the patient, they are not trained or expected to restrain patients who are
acting in a threatening or violent manner.

Advanced control and restraint is an extremely specialised skill, which, due to
the risks involved, requires extensive training and regular practice. As
ambulance staff are not commonly tasked with situations which require

Department
of Health

advanced control and restraint, it would not be possible for them to maintain the
skills at the necessary level to ensure the safety of patients.

My officials have discussed this case with the Association of Ambulance Chief
Executives (AACE). AACE considers that it is neither appropriate nor beneficial to
train all ambulance staff in control and restraint, for the same reasons given above
by NWAS. I fully support the collaborative approach taken by NWAS. As the
control and restraint of patients is a highly specialised area I believe NWAS
personnel rightly rely on the North West police forces to provide this facility as and
when necessary.

I hope that this response is helpful and I am grateful to you for bringing the
circumstances of Miss Pilkington’s death to my attention.

nr shady
we ea
ay

JEREMY HUNT

:

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From the Rt Hon the Earl Howe P.C.

ROS Parliamentary Under Secretary of State for Quality (Lords}
Department
of Health : 09 SEP 2014 Richmond House
: 79 Whitehall
Ms M J Leeming engnden
Senior Coroner
HM Coroner's Court Tel: 020 7210 4850
Paderborn House
Howell Croft North

Bolton BL1 1QY

Thank you for your further letter of 28 May 2014 and the responses you
enclosed from the North West Ambulance Service (NWAS) and Sir Peter
Fahy of Greater Manchester Police. Your letter follows our response of 12
May 2014 to your Regulation 28 report concerning the death of Caroline
Pilkington.

You acknowledge that NWAS staff are trained to provide minimal restraint
in cases where patients lack capacity and there is no perceived risk of harm
to them or the patient, but are not trained or expected to restrain patients
who are acting in a threatening or violent manner.

However, you raise the following concerns:

e that the deceased, Caroline Pilkington, was not acting in either a
threatening or violent manner and infer that this was a case that
could have been handied with the application of minimal
restraint, without the need of Police involvement.

e that there is a training need for ambulance siaff to correctly
identify those cases that can be dealt with by minimal restraint
and those which need Police involvement because health staff are
assaulted or threatened with violence.

e that a failure to distinguish between patients behaving in a
manner due to their illness and those who are being threatening or
violent could delay the removal of a physically unwell patient to
hospital, potentially leading to future deaths.

e That the increasing demand for Police involvement in situations
such as in Miss Pilkington’s case potentially endangers the public
by removing Police Officers from their core duties.

You ask us therefore to consider:
e Whether ambulance personnel should receive further training in
making the distinction described.

Firstly, it needs to be understood that the training of ambulance staff in
control and restraint techniques is not a matter for which the Department of
Health (DH) is responsible. Ambulance staff, for example emergency care
assistants, emergency care practitioners and paramedics, are health
professionals and are trained as such, The actual training that ambulance
staff require and receive in control and restraint is a matter for the NHS
Trust concerned, and not DH.

We have however consulted NWAS and the Association of Ambulance
Chief Executives (AACE) about the further issues you raise.

NWAS has confirmed that a regional protocol is in place that all police
forces it works with, including Greater Manchester Police, have agreed to.
This protocol is under review. However, at the most recent North West
Police Regional Menta! Health Forum, NWAS presented and discussed the
findings from your inquest concerning the death of Caroline Pilkington.
None of the police forces believed there was a need to change the current
policy or reduce the involvement of the police in managing those patients
who required more than minimal restraint.

NWAS confirm that ambulance staff should only request assistance from
the police for patients who elicit a “pathfinder red” outcome (i.e. those
patients who require transfer to an Emergency Department). This in itself
reduces the number of requests for police assistance.

As the need for ambulance personnel to use restraint techniques is
comparatively rare, NWAS believes that the need to train all ambulance
staff in more advanced or specialised restraint techniques is not
demonstrated. Even if all staff were to be trained, it would be difficult to
maintain their skills sufficiently (because of the low incidence of use) to
safely restrain these types of patients when the skills were called for, The
risk is that poorly or inappropriately applied restraint techniques could
cause harm to the patient or to staff.

Department
of Health

In addition, AACE have confirmed that it, as a national organisation, fully
supports the NWAS position. AACE does not feel that the issues you raise
represent a general problem and considers that ambulance staff are
sufficiently trained in restraint techniques to deal with almost all ill or
injured patients and those resisting help. Ambulance staff are trained to
seek assistance from police only when and where they believe it
appropriate and are best placed to make the decision on a case by case basis
as to when police intervention is required.

I hope that this further response is helpful.

lowes Somnceredny

EARL HOWE

GREATER MANCHESTER

POLICE

Sir Peter Fahy Q.P.M., M.A.
Chief Constable

~1 MAY 2014

nora ters

Mrs Jennifer Leeming
Coroner's Office

Greater Manchester West
Ground Floor

Paderborn House

Howell Croft North

Bolton Our ref: IW/LC

BL1 1JW Your Ref:

28" April 2014

Se or pe ne

rar Tits Loamning ,

RE: REGULATION 28 REPORT —- CAROLINE LOUISE PILKINGTON

Thank you for copying me into the report you have submitted in respect of the above case. |
share your concerns about the involvement of police officers in such situations, and | am
grateful for your support in highlighting the risks. All too often, such incidents have led to
demands for police officers to be better trained, an approach which fails to recognise the
underlying issue here.

As you know, | have been concerned for some time about the increasing demand that is
falling on police from gaps in health services. This is evident in many forms, from ‘concern
for welfare’ reports through to police involvement in mental health and accident and
emergency situations. The common theme is a tendency for health professionals to call
police to deal with situations where health professionals already have the appropriate powers
and medical skills, but appear to lack the confidence, will, and particular skills around
incident resolution - which should obviate the need for police involvement. I note in this case
that there were sufficient paramedics present to manage the incident safely without the need
for police involvement, and | understand that the restraint equipment used is carried by
ambulances crews for such purposes. Unfortunately we have been called to similar
incidents at mental health settings, including secure units, where mental health nurses have
also not been trained in control and restraint.

| fully endorse the need for police involvement when health professionals are assaulted or
threatened with violence by those who need dealing with through the criminal justice
system. Clearly we enjoy good operational and professional relationships with our
colleagues across the emergency services, and we have always supported requests for
assistance without question in the past. However, | am increasingly concerned that we are
becoming a default option if the correct medical response is not available, and are being
drawn into high risk medical emergencies. It is difficult to justify the involvement of police
officers in situations which are clearly medical emergencies, whether physical health or
mental health. Our newly revised officer safety training programme has emphasised the
need for officers to recognise the medical risks in situations such as those in Miss

Force Command, Central Park, Northampton Road, Manchester M40 5BP
Tel: 0161 856 2010, Fax: 0161 856 2036, Minicom: 0161 872 6633

Pilkington's case, and to treat those as medical emergencies. While police officers are
trained in restraint, | would suggest that medical emergencies are different, and
consequently require different considerations and approaches. Calling police to deal with
such emergency situations will cause delay, abstract officers from their core duties, and
potentially endanger the patient through failure to take action and/or inappropriate
techniques being used.

In respect of training for the ambulance service, my understanding is that paramedic staff
must receive training in personal safety, which is a requirement through NHS Protect, and an
obligation under health and safety at work responsibilities. However, the content of that
training is not stipulated, and it is down to each service to determine the content and
frequency of that training. | am unclear as to the extent to which their duty of care
responsibilities are understood in relation to controlling and restraining patients. We find
knowledge of the Mental Capacity Act and Mental Health Act is variable, and that some
policies within the ambulance service and hospitals automatically refer incidents to police
when they could take action themselves. | concur with your recommendations, and would be
happy to offer our support to NWAS in respect of any training initiatives they may undertake
in response to your report.

Sir Peter Fahy
Chief Constable

North West Ambulance Service INHS|

NHS Trust
OUR REF: INQ/C/GM/137187 n°) Headquarters
YOUR REF: €a Ladybridge Hall
orecrra: | 75 & y 399 Chorley New Road
4, > Heaton, Bolton
Wy, SO BL1 5DD

Mrs Jennifer Leeming oy

Senior Coroner P|
Coroner’s Office

Greater Manchester West www.nwas.nhs.uk
Ground Floor

Paderborn House

Howell Croft North
Bolton

BL1 UW

05 May 2014
Dear Mrs Leeming
CAROLINE PILKINGTON (DECEASED)

We write further to your letter of 25 March 2014, enclosing a Regulation 28 Report to Prevent
Future Deaths in relation to the inquest examining the death of Caroline Pilkington. Please accept
this as our response in accordance with Regulation 29(4).

We note that you raise concerns regarding the fact that North West Ambulance Service (NWAS)
personnel are not trained in control and restraint techniques and call upon the police service to
assist them in dealing with patients who are unwell, but require control or restraint.

NWAS are acutely aware of the importance of delivering safe patient care and are constantly
striving to improve our procedures. In March 2012 a joint protocol was developed, following
consultation between the North West Region Police Forces and NWAS, which provides a
framework to support inter-agency working and the appropriate use of resources to deliver the
best possible care for patients who lack capacity. The aim of this protocol is to ensure patients
who lack capacity and are refusing advice or treatment, receive care that is in their best interests
using the least restrictive means necessary.

The protocol takes into account the Mental Capacity Act 2005 (MCA), Code of Practice 2007 and
the National Policing Improvement Agency (NPIA) Briefing Note on Applying the Mental Capacity
Act 2010. All 5 police forces in the North West have formally agreed to the protocol.

Protocol for ambulance service requesting police assistance

In accordance with the protocol, ambulance staff may request police assistance for patients who
lack capacity under the following circumstances:

1. Patients in need of emergency treatment who require restraint due to their
threatening or violent behaviour;

Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton. BL1 5DD
Chairman:

Chief Executive: Mr B Williams Fane

=

Delivering the right care, at the right time, in the right place

2. Patients refusing emergency treatment and/or transport in their best interests, where
it has been identified that minimal restraint will be neither effective nor safe to be
undertaken by ambulance staff;

3. Patients who are at risk of causing further harm to themselves or others;

4. Where there are other significant risk factors identified at the scene of the incident that
prevent the patient from receiving treatment or transport to hospital that is in their
best interests.

The police will respond to the incident as an emergency and the ambulance staff and police
officer(s) will then work together and agree a plan on how to manage the patient in the safest,
timeliest and least restrictive means possible.

Ambulance staff will have responsibility for all decisions relating to the clinical treatment of the
patient and will agree with police the appropriate level and type of restraint to be used, taking
into account the patient’s condition/injuries and assessment or treatment required.

Use of restraint by ambulance service staff

Ambulance staff are legally authorised and obliged under the MCA to act in the best interests of,
and provide treatment for, patients who are lacking capacity, even where the patients refuse
treatment or are abusive, threatening or violent.

The MCA also supports the use of reasonable force to ensure that patients lacking capacity receive
care that is in their best interests or are protected from further harm. However, ambulance staff
are neither trained nor expected to restrain patients who are acting in a threatening or violent
manner. Ambulance staff are trained to provide minimal restraint in cases where patients lack
capacity and there is no perceived risk of harm to them or the patient.

NWAS believes that ambulance staff should focus on the treatment of the presenting condition of
their patients. Advanced control and restraint is an extremely specialised skill, which, due to the
risks involved, requires extensive training and regular practice. It would not be feasible for our
staff to be trained in such techniques since situations where control and restraint is required arise
very rarely. Consequently, ambulance staff would not be able to maintain the skills at the
necessary level to ensure appropriate patient care. We believe this has the potential to
compromise, rather than improve, the safety of patients.

NWAS recognises the importance of multi-agency work in the care of patients. Both the police and
ambulance service employ highly skilled, well trained and specialised staff who each have a vital
role to play in the care and safety of the public. We believe that working together is the best way
to achieve consistency and guarantee safety for patients.

We hope that the content of this letter has satisfactorily addressed your concerns. if you require
any further information please do not hesitate to contact us. Alternatively, i Head of
Clinical Governance, has offered to meet with you to discuss the contents of this letter further.

Yours sincerel

Acting Head of Legal Services