Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0126, written 30 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Mar 2015 |
|---|---|
| Reference | 2015-0126 |
| Deceased | Sabrina Stevenson |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Interim Chief Executive London Ambulance Service NHS Trust (LAS) 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST The investigation into the death of Sabrina Stevenson concluded at the end of the inquest on 23 January 2015. The conclusion of the inquest was narrative (Copy attached). 4 CIRCUMSTANCES OF THE DEATH Sabrina Stevenson died on 16 December 2012 from a ruptured ectopic pregnancy; she was aged 28. That morning she began to suffer from abdominal pain, diarrhoea and vomiting; she went on to suffer an episode of collapse. Her flat mate called for an ambulance at approximately 6pm. I have set out below my findings of fact based on the evidence heard, including an independent expert opinion from Professor The initial triaging of the 999 call prompted a clinical callback, rather than ambulance attendance; this represented an ‘undertriaging’ of Sabrina’s condition. The callback did occur within the expected timeframe and retriaged Sabrina as requiring an ambulance to attend within 30 minutes. Demand for ambulances was higher than had been predicted for the time of year. The individual who undertook the callback assessment did not have access to the current response times for ambulances, which were exceeding the intended 30 minute timeframe. A further callback occurred after the timeframe for attendance had past; this call was not made by a clinician and did not provide sufficient safetynet advice to Sabrina. There was also no reassessment of the call categorisation, nor (in the alternative) automated recategorisation at this point. 1 One hour after the initial 999 call an ambulance dispatch was attempted; however, this vehicle was part of a pilot scheme which did not accept patients with diarrhoea and vomiting. As such, the dispatch request was turned down. I concluded that the pilot scheme was appropriately instituted and the nonattendance was inline with the clinical guidance. This conclusion was in contradistinction to the ambulance Trust’s own internal investigation, which was later recanted by the Trust in evidence at the inquest. Three further ambulances were attempted to be dispatched to Sabrina but were diverted to higher priority calls. An ambulance crew first attended Sabrina approximately two hours after the initial 999 call. The focus of this crew was insufficient regarding the potential for serious abdominal pathology as the cause for an initial low blood pressure and raised heart rate. Hypovolaemic shock was not considered in a meaningful way and too much reliance was placed on Sabrina apparently reporting that she had a contraceptive implant in place. This was contrary to the evidence of her GP, who stated that it had previously been removed. Sabrina presented the crew with a difficult situation regarding her pain management and also the assessment of her capacity to make treatment decisions. There was no formal documented assessment of her capacity. Sabrina suffered a further episode of collapse, which was described by the independent expert as the ‘last possible point at which it would be defensible to delay’ extraction out of the flat. A second ambulance crew was requested to assist with extraction. There was a failure of appropriate handover to the second crew. They persisted with an inappropriate assessment focus and insufficient consideration as to whether Sabrina had lost capacity to make treatment decisions. The two crews also failed to consider extraction techniques, other than a carry chair. The independent expert set out that there was a failure either to use a system to allow the patient to be carried flat, or to have such a system available. Sabrina subsequently suffered a catastrophic collapse whilst in the carry chair. She went into cardiac arrest and, despite rapid transport to hospital, arriving at 22.41, she was declared dead at 23.24. I heard evidence from a Consultant Gynaecologist, based at the hospital at which Sabrina died. She stated that, had Sabrina arrived in A&E at a point prior to cardiac arrest, then, on the balance of probabilities, the ectopic pregnancy would have been diagnosed and she would rapidly have had lifesaving surgery. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. After concluding the inquest, I received detailed written submissions from LAS, setting out many changes implemented since Sabrina’s death. I received written submissions from Sabrina’s family in response. I have taken both into account and set out below remaining and additional issues, which it is my duty to raise further. The MATTERS OF CONCERN are as follows. – (1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freedup. I have not been provided with the 2 details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed. (2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall; (3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding; (a) I heard from the consultant Gynaecologist that all women of childbearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene; (b) Given the issues raised by the independent expert regarding extraction techniques, the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance; remain concerned that I (c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed; (4) The potential for systems improvements, such as automated recategorisation, clinical retriaging and feedback to callhandlers regarding current timeframes were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS; (5) The potential for an ‘early warning score’ system, which is specifically validated for prehospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view; (6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations. Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain. It is clear that the Trust are taking further steps to address this; however, more detailed information as to timeframes and progress in this regard are required. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 May 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION 3 I have sent a copy of my report to the Chief Coroner, Sabrina’s family and to other recipients of similar reports arising out of this inquest; namely the The College of Paramedics and NHS England London. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 30 March 2015 Assistant Coroner R Brittain 4
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Regional Director NHS England London 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST The investigation into the death of Sabrina Stevenson concluded at the end of the inquest on 23 January 2015. The conclusion of the inquest was narrative (Copy attached). 4 CIRCUMSTANCES OF THE DEATH Sabrina Stevenson died on 16 December 2012 from a ruptured ectopic pregnancy; she was aged 28. That morning she began to suffer from abdominal pain, diarrhoea and vomiting; she went on to suffer an episode of collapse. Her flat mate called for an ambulance at approximately 6pm. I have set out below my findings of fact based on the evidence heard, including an independent expert opinion from Professor The initial triaging of the 999 call prompted a clinical callback, rather than ambulance attendance; this represented an ‘undertriaging’ of Sabrina’s condition. The callback did occur within the expected timeframe and retriaged Sabrina as requiring an ambulance to attend within 30 minutes. Demand for ambulances was higher than had been predicted for the time of year. The individual who undertook the callback assessment did not have access to the current response times for ambulances, which were exceeding the intended 30 minute timeframe. A further callback occurred after the timeframe for attendance had past; this call was not made by a clinician and did not provide sufficient safetynet advice to Sabrina. There was also no reassessment of the call categorisation, nor (in the alternative) automated recategorisation at this point. One hour after the initial 999 call an ambulance dispatch was attempted; however, this vehicle was part of a pilot scheme which did not accept patients with diarrhoea and 1 vomiting. As such, the dispatch request was turned down. I concluded that the pilot scheme was appropriately instituted and the nonattendance was inline with the clinical guidance. This conclusion was in contradistinction to the ambulance Trust’s own internal investigation, which was later recanted by the Trust in evidence at the inquest. Three further ambulances were attempted to be dispatched to Sabrina but were diverted to higher priority calls. An ambulance crew first attended Sabrina approximately two hours after the initial 999 call. The focus of this crew was insufficient regarding the potential for serious abdominal pathology as the cause for an initial rate. Hypovolaemic shock was not considered in a meaningful way and too much reliance was placed on Sabrina apparently reporting that she had a contraceptive implant in place. This was contrary to the evidence of her GP, who stated that it had previously been removed. Sabrina presented the crew with a difficult situation regarding her pain management and also the assessment of her capacity to make treatment decisions. There was no formal documented assessment of her capacity. low blood pressure and raised heart Sabrina suffered a further episode of collapse, which was described by the independent expert as the ‘last possible point at which it would be defensible to delay’ extraction out of the flat. A second ambulance crew was requested to assist with extraction. There was a failure of appropriate handover to the second crew. They persisted with an inappropriate assessment focus and insufficient consideration as to whether Sabrina had lost capacity to make treatment decisions. The two crews also failed to consider extraction techniques, other than a carry chair. The independent expert set out that there was a failure either to use a system to allow the patient to be carried flat, or to have such a system available. Sabrina subsequently suffered a catastrophic collapse whilst in the carry chair. She went into cardiac arrest and, despite rapid transport to hospital, arriving at 22.41, she was declared dead at 23.24. I heard evidence from a Consultant Gynaecologist, based at the hospital at which Sabrina died. She stated that, had Sabrina arrived in A&E at a point prior to cardiac arrest, then, on the balance of probabilities, the ectopic pregnancy would have been diagnosed and she would rapidly have had lifesaving surgery. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. After concluding the inquest, I received detailed written submissions from LAS, setting out many changes implemented since Sabrina’s death. I received written submissions from Sabrina’s family in response. I have taken both into account and set out below remaining and additional issues, which it is my duty to raise further. The MATTERS OF CONCERN are as follows. – (1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freedup. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has 2 been addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 May 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Sabrina’s family and to other recipients of similar reports arising out of this inquest; namely the The College of Paramedics and LAS. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 30 March 2015 Assistant Coroner R Brittain 3
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) David Hodge Chief Executive College of Paramedics 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST The investigation into the death of Sabrina Stevenson concluded at the end of the inquest on 23 January 2015. The conclusion of the inquest was narrative (Copy attached). 4 CIRCUMSTANCES OF THE DEATH Sabrina Stevenson died on 16 December 2012 from a ruptured ectopic pregnancy; she was aged 28. That morning she began to suffer from abdominal pain, diarrhoea and vomiting; she went on to suffer an episode of collapse. Her flat mate called for an ambulance at approximately 6pm. I have set out below my findings of fact based on the evidence heard, including an independent expert opinion from Professor The initial triaging of the 999 call prompted a clinical callback, rather than ambulance attendance; this represented an ‘undertriaging’ of Sabrina’s condition. The callback did occur within the expected timeframe and retriaged Sabrina as requiring an ambulance to attend within 30 minutes. Demand for ambulances was higher than had been predicted for the time of year. The individual who undertook the callback assessment did not have access to the current response times for ambulances, which were exceeding the intended 30 minute timeframe. A further callback occurred after the timeframe for attendance had past; this call was not made by a clinician and did not provide sufficient safetynet advice to Sabrina. There was also no reassessment of the call categorisation, nor (in the alternative) automated recategorisation at this point. One hour after the initial 999 call an ambulance dispatch was attempted; however, this vehicle was part of a pilot scheme which did not accept patients with diarrhoea and 1 vomiting. As such, the dispatch request was turned down. I concluded that the pilot scheme was appropriately instituted and the nonattendance was inline with the clinical guidance. This conclusion was in contradistinction to the ambulance Trust’s own internal investigation, which was later recanted by the Trust in evidence at the inquest. Three further ambulances were attempted to be dispatched to Sabrina but were diverted to higher priority calls. An ambulance crew first attended Sabrina approximately two hours after the initial 999 call. The focus of this crew was insufficient regarding the potential for serious abdominal pathology as the cause for an initial rate. Hypovolaemic shock was not considered in a meaningful way and too much reliance was placed on Sabrina apparently reporting that she had a contraceptive implant in place. This was contrary to the evidence of her GP, who stated that it had previously been removed. Sabrina presented the crew with a difficult situation regarding her pain management and also the assessment of her capacity to make treatment decisions. There was no formal documented assessment of her capacity. low blood pressure and raised heart Sabrina suffered a further episode of collapse, which was described by the independent expert as the ‘last possible point at which it would be defensible to delay’ extraction out of the flat. A second ambulance crew was requested to assist with extraction. There was a failure of appropriate handover to the second crew. They persisted with an inappropriate assessment focus and insufficient consideration as to whether Sabrina had lost capacity to make treatment decisions. The two crews also failed to consider extraction techniques, other than a carry chair. The independent expert set out that there was a failure either to use a system to allow the patient to be carried flat, or to have such a system available. Sabrina subsequently suffered a catastrophic collapse whilst in the carry chair. She went into cardiac arrest and, despite rapid transport to hospital, arriving at 22.41, she was declared dead at 23.24. I heard evidence from a Consultant Gynaecologist, based at the hospital at which Sabrina died. She stated that, had Sabrina arrived in A&E at a point prior to cardiac arrest, then, on the balance of probabilities, the ectopic pregnancy would have been diagnosed and she would rapidly have had lifesaving surgery. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. After concluding the inquest, I received detailed written submissions from LAS, setting out many changes implemented since Sabrina’s death. I received written submissions from Sabrina’s family in response. I have taken both into account and set out below remaining and additional issues, which it is my duty to raise further. The MATTERS OF CONCERN are as follows. – (1) The potential for an ‘early warning score’ system, which is specifically validated for prehospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view and I believe that the College of Paramedics may be in a position to assist in this process; (2) I am concerned by evidence provided from LAS that there are 400 vacant 2 positions within the Trust. This connotes a significant recruitment issue for the profession, which could risk future deaths occurring simply through a lack of available trained paramedics; (3) A related issue was raised at the inquest, regarding whether the increasingly complex clinical role of paramedics means that they should be recruited through graduate, rather than vocational schemes. I am sufficiently concerned by the apparent variation in training that I consider this issue to warrant consideration; (4) Concern has been raised by Sabrina’s family, with whom I concur, that the the consultant Manchester Triage System should reflect Gynaecologist; that any woman of childbearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing. the evidence of 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 May 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Sabrina’s family and to other recipients of similar reports arising out of this inquest; namely NHS England London and LAS. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 30 March 2015 Assistant Coroner R Brittain 3
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr R Brittain Assistant Coroner for Inner London North Sent via email only to Dear Mr Brittain Death of Sabrina Stevenson (died 16.12.2012): Report to Prevent Future Deaths I am responding to your letter of 30 March 2015 regarding your concerns following the inquest into the death of Sabrina Stevenson. The College of Paramedics is saddened to learn of this tragic event and sends its condolences to Sabrina's family and friends. The College will do everything it can within its scope to influence future paramedic services where there are similar patient circumstances. Before setting out the actions proposed by the College of Paramedics, it may be helpful to provide an explanation of the role of the College as the professional body for paramedics in the UK and that of other organisations which set standards and guidelines for paramedic practice. The College of Paramedics, formerly the British Paramedic Association, was established in 2001 following formal registration of paramedics in the UK. Over the last 14 years the College has developed its capacity and capability and built up a membership which currently represents 22 percent of UK paramedic registrants. Since 2006 the College has offered best practice guidance on curricula for paramedic education and is currently producing a paramedic post-registration career framework. The College has recently established an expert paramedic group which through time will significantly contribute to guidance on paramedic clinical practice for the profession across all sectors. While the College has no regulatory powers or authority to ensure paramedics, the UK ambulance services or higher education institutions take up the guidance it produces, it works closely with several other organisations which have important roles in setting standards and determining clinical practice. The most significant of those are briefly described below: 1. The Health and Care Professions Council (HCPC), which is the statutory regulator for paramedics, sets the Standards of Proficiency (SoPs) and the Standards for Education and Training (SETs); 2. The Association of Ambulance Chief Executives (AACE) is the body that represents NHS ambulance 3. services in the UK for which the National Ambulance Services Medical Directors (NASMeD) determine local clinical practice in each of the members' ambulance services; and, In conjunction with the AACE and NASMeD, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) develops clinical practice guidelines for paramedics. The College of Paramedics is represented on the JRCALC. 1 of 7 The College of Paramedics' responses to each of your concerns are set out in the following pages and I hope you feel the actions we have outlined fully address those. Please do not hesitate to contact the College if you require further detail or believe we can be of further assistance. Yours sincerely D J Hodge Chief Executive Cc Chair of the College of Paramedics Vice-Chair of the College of Paramedics , Vice-Chair of the College of Paramedics Interim Executive Director of the College of Paramedics College of Paramedics, The Exchange, Bristol Road, Bridgwater, TA6 4RR Tel: 01278 420014 email: membership@collegeofparamedics.co.uk Website: www.collegeofparamedics.co.uk 2 of 7 Our comments, previous actions, and further actions Your concern (1) The potential for an ‘early warning score’ system, which is specifically validated for prehospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view and I believe that the College of Paramedics may be in a position to assist in this process; Our comments on concern (1) The College of Paramedics supports the use of a standard early warning system for which there is valid evidence for use in the pre-hospital setting and which would be compatible with systems used by acute and receiving trusts. We are aware that the National Early Warning Score(NEWS) is the early warning score system that has been developed and suggested for use throughout the NHS but we also understand that this system has not been specifically validated in the pre-hospital setting and the evidence for its pre-hospital use is only starting to be generated. As NEWS was not specifically designed for pre-hospital use the pre-hospital actions to be taken linked to varying NEWS (scores) may require further research or developmental work. We are advised by one of our members who has had a paper on early warning systems published (McClelland, 2015) that the value of NEWS in the pre-hospital setting relies on NEWS also being used in the receiving healthcare settings. McClelland noted that recent work by Silcock et al (2015) has linked a high pre-hospital NEWS to increased mortality but notes that this may be the first large study in this area. We believe this would be a significant project which would require input and collaboration amongst the key organisations in pre-hospital care. References: McClelland G (2015) A Retrospective observational study to explore the introduction of NEWS in NEAS. Journal of Paramedic Practice. 7(2):80-9 Silcock DJ, Corfield AR, Gowens PA, Rooney KD. Validation of the National Early Warning Score in the prehospital setting. Resuscitation. 2015;89:31-35 Our actions for concern (1) 1. As a member of the JRCALC, the College of Paramedics will raise the issue of a national early warning system with the JRCALC and propose that this work is scheduled into the JRCALC workstream. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 2. The College of Paramedics will participate on any working groups or committees that might be convened at a national level to develop and establish an effective national early warning system that can be applied in pre-hospital care and which would be compatible with receiving health facilities. 3. Should a national early warning score be agreed upon and recommended by the JRCALC, the College would promote the national early warning score through its electronic communications to its members, its quarterly newsletter, and its national continuing professional development programme. Yours concern (2) I am concerned by evidence provided from LAS that there are 400 vacant positions within the Trust. This connotes a significant recruitment issue for the profession, which could risk future deaths occurring simply through a lack of available trained paramedics; 3 of 7 Our comments on concern (2) The College has recently voiced its concerns through the media in regards to the increasing demand on paramedic services and the parallel shortage of paramedics in the UK and is concerned to see so many vacancies in a number of ambulance services. The College of Paramedics does not commission education for paramedics. However, the College has previously responded to consultations by the Centre for Workforce Intelligence (CfWI) and has noted that in early 2015 the Migration Advisory Committee has recommended that paramedics qualified to NQF 6+ should be included in the shortage occupation list. The College has also made application for student paramedics to be eligible for NHS bursaries. Unlike other healthcare students, who do not pay for their university tuition fees, student paramedics have to bear either all or most of their educational costs themselves. We believe this would be a significant factor in attracting students to a career as a paramedic. The position in regards to progress of this application is covered under the next section which addresses Concern (3) Our actions for concern (2) Previous actions 1. The College of Paramedics undertook a survey of Higher Education providers regarding Paramedic Science education at the end of 2011 and provided the CfWI the results and we noted that the Migration Advisory Committee has recommended that paramedics qualified to NQF 6+ should be included in the shortage occupation list. 2. The College made application to the Department of Health on 16 August 2012 for student paramedics to be included in the NHS Bursary Scheme and the final decision is due to be recommended to the Department of Health by HEE in June 2015 Further actions 1. Through our website, we will continue to promote the paramedic profession as an attractive and rewarding career; 2. We will write to all NHS ambulance services as employers of paramedics and to HEIs to offer our assistance in their activities which aim to recruit student paramedics and paramedics. We will do this by 5 June 2015 Reference See 'Partial review of the Shortage Occupation Lists for the UK and for Scotland' by the Migration Advisory Service, February 2015. Pages 56-60 set out the Committee's findings for paramedics. Viewed via the Centre for Workforce Intelligence website. [Accessed 20th May 2015] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/406775/Partial_review_of_ the_SOL_for_UK_and_Scotland_Report.pdf Your concern (3) A related issue was raised at the inquest, regarding whether the increasingly complex clinical role of paramedics means that they should be recruited through graduate, rather than vocational schemes. I am sufficiently concerned by the apparent variation in training that I consider this issue to warrant consideration; Our comments on concern (3) Unlike most other health professions, entry to the paramedic register requires the equivalent of a Certificate in Higher Education. The College has long held the view that entry should require degree level education for paramedics, mainly due to the increasing complexity of paramedic services. Moreover, some registered 4 of 7 paramedics move into specialist and advanced roles which are recognised in the College's post-registration framework. This position coupled with the fact there has been wide variation in courses and awards leading to paramedic qualification led to the College funding the Paramedic Evidence-based Education Project (PEEP) in 2012 which has since led to a major project being led by Health Education England (HEE).The Chair of the College of Paramedics has co-chaired the HEE PEEP Steering Group, and senior College members have provided representation into its sub-groups. The recommendations from the Steering Group are due to be published in June 2015 following approval by the Department of Health. As part of the HEE PEEP Steering Group work, a review of the College of Paramedics' Paramedic Curriculum Guidance, the College of Paramedics Paramedic Post Registration – Career Framework, and the College of Paramedics Scope of Practice Policy was reviewed by an independent body [Institute of Education]. This was to ensure parity with other Allied Health Professions and confirm that the Paramedic Curriculum Guidance was at the appropriate Higher Education standard. The College of Paramedics has addressed the comments raised by both the independent body and HEE and the revised documents will be published in May or June 2015. The College off Paramedics offers an endorsement process and award to HEIs and education providers for paramedic courses that meet its curriculum guidance. The College recommends that only those programmes approved by the statutory regulator, and ‘endorsed’ by the professional body, should be commissioned by the Local Education & Training Boards (LETBs). While entry to the paramedic register is on completion of a course approved by the regulator (the HCPC), the College of Paramedics firmly believes that these courses should be a BSc (Hons) degree at academic level 6 in England, Wales and Northern Ireland, and SHE level 3 (SCQF10) in Scotland. Our actions for concern (3) Previous actions 1. 2. In 2011, the College responded to a circular from the Department of Health which invited eligible professions and workforce to apply for access to the NHS Bursary Scheme. In January 2012 we were advised that the application had met the criteria for stage 1 and it would proceed for financial analysis. In April 2013 we were advised by the Head of Education Funding at the Department of Health that the financial responsibility had been transferred to HEE and that the outcome of the application for student paramedics having access to bursaries would be considered by HEE in its review of the PEEP report recommendations which is noted at point 2 below; In 2012, the College of Paramedics funded the Paramedic Evidence-based Education Report (PEEP) which was commissioned by the Department of Health (England) National Allied Health Professions Advisory Board. The PEEP report was published in August 2013 and has resulted in HEE reviewing the recommendations made in the report which as previously noted will be published in late June 2015; Further actions 1. The College of Paramedics will write to the ambulance services and HEIs advising of the revised Paramedic Curriculum Guidance once published and offer our assistance in course development through the availability of the College's course endorsement process. We will write to those organisations by the 30th June 2015. 2. The College will assist wherever possible in the implementation of recommendations from the pending HEE report; and, 3. The College will advise the Coroner of the recommendations from the HEE report once published 5 of 7 Your concern (4) Concern has been raised by Sabrina’s family, with whom I concur, that the Manchester Triage System should reflect the evidence of the consultant Gynaecologist; that any woman of childbearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing Our comments on concern (4) The College supports the recommendation made by the Consultant Gynaecologist regarding all women within an age range who have abdominal pain being suspected of being pregnant unless proven otherwise. We understand that the Manchester Triage System (MTS) tool is widely used in emergency departments across the UK but is not used widely by paramedics at the point of patient contact, although some ambulance services have employed a derivative of the tool in operational practice, named ‘Paramedic Pathfinder’. Paramedic Pathfinder does include a validated pre-hospital Early Warning Score system (PHEWS) but this is not aligned to the National Early Warning Score (NEWS) detailed above. As such some other services have chosen to use NEWS, despite the absence of a proven efficacy in pre-hospital use. This concern is similar to concern (1) and should be considered by the JRCALC. Our actions for concern (4) These actions would be the same as those noted under concern (1) since we believe the two issues would be dealt with under a single project. 1. The College of Paramedics will advise the JRCALC of the recommendation made by the Consultant Gynaecologist and propose that this work is scheduled into the JRCALC workstream. As in our actions for concern (1) we will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 2. The College of Paramedics will take the issue of triage tools, such as the Manchester Triage System and Paramedic Pathfinder to the JRCALC and propose that work is undertaken to explore the inclusion of formalised triage tools into the next iteration of the JRCALC clinical practice guidelines. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 Other action we will take 1. The College of Paramedics will include a clinical case study and expert commentary on potential ruptured ectopic pregnancy in its August 2015 newsletter which will aim to increase awareness of the risks associated with such cases 6 of 7 Our further actions summarised For concern (1) 1. As a member of the JRCALC, the College of Paramedics will raise the issue of a national early warning system with the JRCALC and propose that this work is scheduled into the JRCALC workstream. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 2. The College of Paramedics will participate on any working groups or committees that might be convened at a national level to develop and establish an effective national early warning system that can be applied in pre-hospital care and which would be compatible with receiving health facilities. 3. Should a national early warning score be agreed upon and recommended by the JRCALC, the College would promote the national early warning score through its electronic communications to its members, its quarterly newsletter, and its national continuing professional development programme For concern (2) 1. Through our website, we will continue to promote the paramedic profession as an attractive and rewarding career; 2. We will write to all NHS ambulance services as employers of paramedics and to HEIs to offer our assistance in their activities which aim to recruit student paramedics and paramedics. We will do this by the 5th June 2015. Our actions for concern (3) 1. The College of Paramedics will write to the ambulance services and HEIs advising of the revised Paramedic Curriculum Guidance once published and offer our assistance in course development through the availability of the College's course endorsement process. We will write to those organisations by the30th June 2015. 2. The College will assist wherever possible in the implementation of recommendations from the pending HEE report; and, 3. The College will advise the Coroner of the recommendations from the HEE report once published For concern (4) 1. The College of Paramedics will advise the JRCALC of the recommendation made by the Consultant Gynaecologist and propose that this work is scheduled into the JRCALC workstream. As in our actions for concern (1) we will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 2. The College of Paramedics will take the issue of triage tools, such as the Manchester Triage System and Paramedic Pathfinder to the JRCALC and propose that work is undertaken to explore the inclusion of formalised triage tools into the next iteration of the JRCALC clinical practice guidelines. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015 Other action we will take 1. The College of Paramedics will include a case study and expert commentary on potential ruptured ectopic pregnancy in its August 2015 newsletter which will aim to increase awareness of the risks associated with such cases 7 of 7
Executive Office Headquarters 220 Waterloo Road London SE1 8SD Tel. 020 3069 0240 Email: Dr R Brittain Assistant Coroner St Pancras Coroners Court Camley Street London N1C 4PP Our ref: INQ/7736/12 22 May 2015 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS arising from the investigation into the death of Sabrina Stevenson : response by the London Ambulance Service Dear Dr Brittain Thank you for your Regulation 28 Report to prevent future deaths, dated 30 March 2015, bringing to my attention the Coroner’s concerns arising from the inquest into the death of Sabrina Stevenson. We have given careful consideration to each concern and consulted with the National Ambulance Service Medical Directors’ Group, our Consultant Midwife, and other senior clinicians within the London Ambulance Service NHS Trust to reply. Taking the concerns in turn I set out the actions we have taken and response: 1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed. On 23 April 2015 I wrote to all LAS staff to inform them of the additional investment the LAS had secured. “I wanted to share the news that we are in final negotiations with our GP commissioners about investing around an additional £27.2m for 15\16, including funding for increased activity. A further £5m will be funded from within the Service. This funding from GP clinical commissioning groups will be released over the year as we achieve milestones around performance, recruitment and productivity. 1 The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff rest-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals. To help manage the increased demand we are growing the workforce, responding to patients in new ways and improving the way we work. A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital. We hope to finalise the contract in the next few days, but I wanted to keep you informed of progress.” On 14 May 2015 the LAS Operating Plan 2015/16, copy attached, was submitted to the Trust Development Authority outlining the priorities for the year including: improving the quality and delivery of our urgent and emergency response; making the LAS a great place to work; improving our organisation and infrastructure; and developing the leadership and management capabilities within the LAS. The LAS Operating Plan 2015/16 also sets out the milestones towards meeting the operational performance standards; the measures relating to the workforce, including improving staff morale, reducing turnover, the recruitment of front line staff, and staff engagement; and the quality and safety priorities for the LAS will be assessed by the Care Quality Commission. Throughout the year the Trust Development Authority and NHS England will scrutinise the LAS’s achievement of the LAS’s Operating Plan and the investment agreed will be subject to meeting the milestones. 2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall. The progress achieved in the recruitment programme is outlined in the report “Recruitment Progress” 15 May 2015. The recruitment summary sets out the position to recruit for recruiting paramedics nationally and internationally and recruiting Trainee Emergency Ambulance Crew staff (TEACs). The operational staff trajectory indicates that by October 2015 the LAS is aiming to recruit to a target establishment of 3004 front line staff which provides a vacancy rate of 5% to be covered by staff working overtime. 3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding; (a) I heard from the consultant Gynaecologist that all women of childbearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene; 2 To inform our decision about the introduction of pregnancy testing the Medical Director approached all of the Ambulance Service Medical Directors to ascertain if and where pregnancy testing was undertaken in the pre-hospital environment. The overwhelming response was that pregnancy testing was not undertaken by other ambulance services routinely with the exception of a small number of advanced trained practitioners in Wales. As indicated the Regulation 28 Report was shared with the National Ambulance Service Medical Directors’ Group (NASMeD) and the Chair confirmed that the national guidance for ambulance staff with regard to the assessment of women of child bearing age would be reviewed and any recommendations for change in the future would be considered and discussed by NASMed. The Medical Director also asked the Consultant Midwife to offer her clinical opinion on ectopic pregnancy. The Consultant Midwife wrote: In the pre-hospital setting: It is reasonable to assume that any woman of reproductive age (8-60 years) could be pregnant. This is based on the evidence that early menarche has been observed in population studies associated with improved nutrition, and at the later end of the menarche with the oldest spontaneous conception occurring at age 59 years. The Office of National Statistics (2011) detailed below highlight the age group classification for maternal age at birth per 1,000 deliveries, the births reported above 44 years of age are incorporated into the 40-44 grouping, but support the above assumption in that with their reported ranges from 15 to 44 years. With women now seeking artificial methods for pregnancy, both within and outside of the UK, the possibility of pregnancy at extremes of age must be assumed when a woman presents with symptoms that could be pregnancy related. The guideline development group (GDC) from the National Institute for Health and Care Excellence (2014) agree that because of a wide range of symptoms associated with ectopic pregnancy, including non-specific symptoms such as gastro-intestinal symptoms, it is appropriate that healthcare professionals providing care for this group should have access to pregnancy tests and enable timely referral. 3 NICE (2014) recommend that women who are haemodynamically unstable should be referred directly to an Emergency Department (ED), the London Ambulance Service would recommend this management in the first instance, and do not currently have the facility to undertake rapid diagnostic assessment of beta human chorionic-gonadotropin (B-HCG) to ascertain the presence of a pregnancy in this group of women without the potential for delay on scene. The current methods for ascertaining pregnancy involve the use of urinary measurement of b-HCG, which would rely on a woman to be well enough to pass urine, and a period of 3-5 minutes for a result to be realised for the crew on scene. The benefit that this would afford would be that where symptoms were present and pregnancy was confirmed that an early pregnancy pathway could be utilised for the woman enhancing consultation with a gynaecologist in the first instance rather than via the ED. The undertaking of an on-scene test would add a potential delay in conveyance in the first instance and may not be possible where the woman was unwell and requires immediate conveyance. The ideal solution would be a “near patient” test diagnostic solution where a small blood sample could be used to provide a confirmation en-route so there is not delay to conveyance but ensured the woman was seen in the right place, that of either the ED or an early pregnancy unit where further testing could be undertaken. After careful consideration of the Consultant Midwife’s clinical opinion, the feedback from other ambulance services, and mindful of the potential impact on response times and the capacity to undertake the necessary training, the Medical Director of the LAS concluded that in the immediate future the LAS would not be in a position to introduce pregnancy testing. Providing appropriate training, quality assurance, infection control and disposal of body waste would present significant difficulty if pregnancy testing was introduced in the pre- hospital setting. Further the management of the patient who was unexpectedly found to have a positive pregnancy test was currently outside of the practice of a paramedic; conversely some patients may be given false reassurance from a negative test. (b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance; The advice from the Medical Directorate in the Clinical Routine Information Bulletin to be issued on 26 May 2015 to all staff is given below. Staff are reminded that are a range of options to consider when there are challenges removing a patient from scene, this includes where it is not appropriate for the carry chair to be used either due to the clinical presentation of the patient or physical difficulties in using the carry chair. Additional resources can be requested via EOC to provide additional hands to help carry a patient. Further options include the use of the carry sheet, the use of the spinal board and straps. There is also specialist additional lifting equipment carried by both Hazardous Area Response Team (HART) and the advanced paramedic practitioners (APPs). A carry sheet should be carried on every frontline ambulance as per the current stocking lists these are single use and are available to order via the electronic procurement system (EPROC). (c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant 4 points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed. A copy of the case study entitled “Learning from Experience” in the mandatory Core Skills refresher training programme 2015. 1 is attached. The case study covers ectopic pregnancy, hypovolaemia, and fluctuating capacity. Also attached is a copy of the achievement record identifying the learner outcomes and objectives completed by the tutor and “student”. As at the 19 May 2015 347 staff (11% of operational staff) had completed the Core Skills refresher training programme, and the remainder of operational staff are expected to complete their training by 3 July 2015. (4) The potential for systems improvements, such as automated re-categorisation, clinical re- triaging and feedback to call handlers regarding current timeframes were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS. The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS implements its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result. The Clinical Hub has refined and developed its processes, skill mix and staffing levels since its inception on 2 December 2013 and an increased level of staffing within the Clinical Hub in the Emergency Operations Centres has negated the need for any automated processes. Staff have clear standard operating procedures in place for the management of Held call, vulnerable patients and calls being held awaiting assessment. The demand management plan itself has been reviewed and replaced with the surge management plan, which has a number of criteria for allowing progression through the plan and a scored matrix to evidence and inform any decision made. The LAS has considered a facility whereby call handlers have real-time information relating to current waiting times for patients. This process is currently being reviewed by the Management Information and Governance Committees within the Trust for accuracy, appropriateness and suitability in a dynamically fast changing environment. It is essential that this is given careful consideration so that the most accurate information is passed on to patients, without having any detrimental impact on them, their carers or their 3rd party informants. 5) The potential for an ‘early warning score’ system, which is specifically validated for pre- hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view. As with the introduction of pregnancy testing the Medical Director sought the views of National Ambulance Service Medical Directors’ Group (NASMeD) at their meeting on 21 April 2015 on the use of a national early warning score (NEWS) system in the pre-hospital environment to inform our assessment of the feasibility of introducing an early warning score 5 system in London. The Chair of NASMed confirmed that while the NEWS system was recently approved for pre hospital use, and is used by Yorkshire Ambulance Service, there would need to be a discussion with the both the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and then NASMeD on whether the system could be recommended for use nationally or cited as an example of such a scoring system. There is currently no evidence on how applicable or sensitive NEWS scoring would be in the cases of gynaecological or obstetric collapse. Therefore the Medical Director of the LAS is reviewing the possibility of introducing NEWS scoring with the understanding it is more sensitive for conditions like sepsis. (6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations. Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain. It is clear that the Trust are taking further steps to address this; however, more detailed information as to timeframes and progress in this regard are required. The governance processes relating to serious incident investigations are outlined in the Serious Incident Policy and Procedure, TP/006 most recently updated on 1 April 2015. The Serious Incident Policy and Procedure sets out the responsibilities from the Trust Board, to the Quality Governance Committee, individual directors and senior managers, and management groups in the LAS, as well as and all members of staff for reporting incidents, for investigating serious incidents, and taking action to reduce the risk of recurrence and / or mitigate the harm that may be caused. The Quality Governance Committee, which meets quarterly, has had and will continue to have a key role in seeking an assurance that the processes in the Serious Incident Policy and Procedure are being complied with and are robust; that incidents are being reported appropriately and identified as serious incidents; that when serious incidents are declared by the Serious Incident Group the root causes are identified and investigated; that lessons are being learned and actions are monitored and completed. The minutes of the Quality Governance Committee evidence that improvements in the timeliness in which investigations are completed are being monitored and that the Director of Corporate Affairs and Head of Governance and Assurance have been asked to provide further assurance as to the processes for ensuring that a thorough investigation is completed which is approved by a member of the Senior Management Team and a director from the Executive Management Team. The Procedure for Responding to Enquiries and giving evidence at Coroners Inquests and statements at Police interviews, TP/015, most recently updated and submitted to the Senior Management Team for approval on 27 May 2015 also states that staff who provide statements for a serious incident investigation and to the Coroner for an inquest receive feedback from the serious incident investigation and a copy of the serious incident investigation report. In addition to seeking an assurance that the Serious Incident Policy and Procedure is being complied with the Quality Governance Committee will also be seeking an assurance that the statutory duty of candour is being complied with for notifiable safety incidents which include a broader range of incidents than those captured by the serious incident criteria. A copy of the Serious Incident Policy and Procedure, the draft Procedure for Responding to Enquiries and giving evidence at Coroners Inquests and statements at Police interviews, TP/015, and Duty of Candour Policy are enclosed with this reply. I hope that you and indeed Sabrina’s family will be reassured by the actions the LAS has taken and will continue to take to address your concerns. 6 Yours sincerely Chief Executive Officer & Consultant in Emergency Medicine London Ambulance Service NHS Trust Consultant in Emergency Medicine Enclosures: The London Ambulance Service Operating Plan 2015/16 Recruitment Progress, 15 May 2015 “Learning from Experience” in the mandatory Core Skills refresher training programme 2015. 1 Achievement Record CSR.1 Serious Incident Policy and Procedure, TP/006 Draft Responding to enquiries from Coroners, Police, the IPCC and others in relation to interviews, the preparation of statements and giving evidence at Inquests and other Court Hearings, TP/015 7
NHS England Southside 105 Victoria Street London SW1E 6QT 1st June 2015 Mr R Brittain Assistant Coroner Inner London North 1st floor St Pancras Coroners Court Camley Street London N1C 4PP Dear Mr Brittain, REGULATION 28: REPORT TO PREVENT FUTURE DEATHS – Sabrina Stevenson Thank you for your report dated on 30 March 2015, relating to the following matter of concern: “Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be free up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.” I would like to offer my sincere apologies for not meeting your deadline of 25 May. The duties that NHS England has in relation to LAS are: Assurance of the CCG in respect of their commissioning arrangements, including contract management, quality oversight and delivery of national standards; Direct oversight of LAS in respect of their emergency planning and resilience planning and capability. NHS England also leads on generic system resilience in London, in which LAS is a lead provider. During 2014, LAS found operational delivery against national standards increasingly challenged. NHS England together with Brent CCG (who commissions LAS services on behalf of London’s 32 CCGs), the NHS Trust Development Agency (TDA) and 1 LAS undertook a number of steps to ensure the service remained resilient, safe and to secure improved ambulance response times in 2015. I will cover each step in turn: 1. Operational resilience Operational performance was reviewed weekly by TDA, Brent CCG and ourselves throughout the winter of 2014/15. These reviews resulted in agreed additional actions to ensure the LAS could respond as effectively as it could within the ambulance resource available. Response times for Category A incidents has been improving since December 2014 and the LAS are meeting the agreed improved performance target. NHS England, London Region and TDA also commissioned a diagnostic review of the key drivers of underperformance. The key findings were that utilisation of the service had increased significantly so impacting on the operational capability of the service. Utilisation levels are driven by the number of Category A incidents, the job cycle time and the number of vehicle hours. During the last year, the level of Category A incidents had risen and available vehicle hours had reduced and the nominal net turnover rate was rising. The requirement to reduce utilisation rates became a key objective for securing medium and long term resilience of the service. The business case agreed by London CCGs and the TDA aims to improve ambulance response times on a sustainable basis by reducing vehicle utilisation to optimal levels. As requested, further details of the business case investment are provided below. 2. External Clinical Review During 2014, Serious Incidents (SIs) and complaints also rose. Although the causes of these were unclear; there was evidence that an increased focus on clinical risk management systems in the LAS and increased awareness of SIs could be contributory causes. In December 2014, NHS England commissioned an external clinical review of the London Ambulance Service (LAS) to assess the adequacy of LAS clinical risk management systems, deployed in the context of a significant vacancy position and rising service demand. This involved a multi-professional Clinical Review Panel, including members with Urgent and Emergency Care Systems expertise from London, outside London and LAS members. The panel was National Clinical Director for Urgent Care, chaired by NHS England. The purpose of the review was to assess the adequacy of the clinical risk management systems that the Trust has deployed. The review also considered those actions that could be put in place immediately (December 2014 through January 2015) and those medium to long term actions that could strengthen clinical risk management within LAS by: Reviewing LAS corporate clinical governance/risk management arrangements 2 Specifically including a review of the Control Room and Hub; choices made at call taking outside the Advanced Medical Priority Dispatch System (AMPDS), alternative transport options and how those decisions are made Making recommendations to the London Regional Director of NHS England for what could be put in place within LAS to further mitigate clinical risk. The final report from the Review Panel was published on 17 December 2014. It found that the current governance structures and risk management processes supporting the day-to-day management and escalation of risks at the LAS, appeared robust, but made a number of recommendations to improve the management of risk. An overview group including NHS England, TDA, LAS and Brent CCG was formed. The Group agreed to accept all the recommendations. There is a delivery plan to ensure the implementation of the recommendations. This plan is reviewed by NHS England LAS Oversight Group on a quarterly basis chaired by the Chief Operating Officer for NHS England London Region. 3. Investment business case and NHS contract for LAS in 2015/16 NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG. The LAS contract for 2015/16 includes agreed improved performance and lower utilisation standards by month from May 2015. Performance is planned to meet the national standard in September and exceed the standard from November. These performance indicators are reviewed monthly by the LAS Contracts and Performance Group. For April and May, the LAS have performed above the agreed ambulance response time standard. The additional money will be spent increasing staffing and capacity to help better manage peaks in demand and to reduce utilisation rates so that the national standard of 75% of Category A calls being met within 8 minutes is achieved from September 2015. A total of 850 staff will be recruited in 2015/16. This includes around 150 new posts. Investment will also cover new ambulance vehicles and specialist clinical teams in the clinical hub to support GP and primary care referrals. 3 The agreed improvement programme also includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital. I was very sorry to learn of the death of Sabrina Stevenson through your Regulation 28 report. I hope that my response has given you assurance that NHS England has taken sufficient steps to demonstrate that the risk of future deaths, from increasing response times, has been addressed. Yours sincerely Regional Director NHS England, London 4
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.