Barbara Patterson

Care Quality
Commission

Care Quality Commission
Citygate

Gallowgate

Newcastle upon Tyne

NE1 4PA

Telephone:03000 616161
information.access@cqc.org.uk

www.cqc.org.uk

Mr T Brown

HM Senior Coroner North Northumberland
17 Church Street

Berwick upon Tweed

TD15 1EE

3 July 2015
Dear Mr Brown

Re: Inquest into the death of Barbara Patterson.

We were sorry to read about the death of Ms Patterson and the circumstances in
which she died. Thank you for your report and the requirement for us to review what
actions should be taken.

Please treat this letter as the formal response of the Care Quality Commission
(CQC) to your report dated 21 May 2015.

In your report and pursuant to the requirements under paragraph 7, schedule 5 of
the Coroners Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, you require the CQC to provide details of any
action that has been taken or which is proposed to be taken in response to the
concerns highlighted in your report, or an explanation as to why no action is
proposed if appropriate.

Background

Before the death of Barbara Patterson we carried out unannounced visits to North
East Ambulance Service NHS Foundation Trust (NEAS) which involved visits to four
ambulance stations and the emergency contro! centre on 4, 5, 6, 7 and 13 February
2014.

Following that inspection we identified areas of non compliance against the following
regulations detailed in the Health and Social Care Act (2008):

e Regulation 10 (1)(b)(2)(b)(i) Assessing and monitoring the quality of service
provision;

e Regulation 13 Management of Medicines;
e Regulation 23(1)(a) Supporting Workers;
e Regulation 21(a)(i) Requirements relating to workers;

Following submission of the final report we instructed NEAS to submit an action plan.
The Action Plan was duly presented to CQC by NEAS within the required timescale
and, recognising that the Service required a reasonable period of time to implement
the proposed measures, regular meetings were scheduled and conducted between
CQC and NEAS, to monitor the progress of their implementation. This process was
undergoing at the time of Mrs Patterson’s death.

Matters of Concern

1. The failure of the call handler to give out timely advice in respect of
CPR.

The CQC intend to carry out a planned comprehensive inspection of North East
Ambulance Service (NEAS) as part of its ongoing inspection process. During this
inspection we will investigate to what extent and degree call handlers are supported
by systems and procedures already in place. We will also require NEAS to furnish
oral and written evidence to demonstrate that they understand their role and
responsibilities in relation to call handlers and that they provide regular monitoring to
ensure that the system is functioning at an appropriate tevel.

2. Deficiencies in Pathways System

As recognised in your report, the Pathways system is a National Programme, piloted
in the North East, which has been introduced in other areas of the country. We have
written to NEAS to instruct them to submit evidence of how they are mitigating the
tisk within the Pathways system and also how they are working with Pathways to
improve the system.

3. Failure of ambulance dispatcher to dispatch an ambulance
closer to the deceased’s location

This issue will be included as part of our planned comprehensive inspection and
investigated to ascertain whether procedures presently in place by NEAS relating to
the dispatch of ambulances is appropriate and what, if any, improvements can be
made to the current system. Additionally, we will be meeting with NEAS in
September 2015 to discuss how they are managing the process of dispatching
ambulances.

4. Target time for arrival of ambulance in 8 minutes was breached.

This issue will be included as part of our planned comprehensive inspection and
investigated to ascertain whether procedures presently in place relating to dispatch

of ambulances is appropriate and what, if any, improvements can be made to the
current system. We have written to NEAS fo instruct them to submit evidence of their
current position around breaches of arrival times of their ambulances together with
providing evidence of how they are mitigating the risk for of reducing the missed
target times of ambulance arrivals.

5. National shortage of paramedics, which is particularly acute in the North
East

We will be meeting with NEAS in September 2015 to discuss and monitor how they
are managing their delivery of the service, what is their current position of staffing
levels and identified vacant posts and their current recruitment position.

6. Delay at handover of patients to A & E staff which jeopardises
availability of ambulance staff

We will be meeting with NEAS in September 2015 to discuss how they are managing
the handover process to A & E services and how they are working collaboratively
with all providers and stakeholders to ensure a smooth and timely handover process.
In addition, this issue will be reviewed as part of our planned full comprehensive
inspection of North East Ambulance Service (NEAS).

We greatly appreciate the information you have provided us in your report and
please do not hesitate to contact me with any further questions you may have.

With best wishes.

Yours sincerely

Head 5 = Inspections — North East

4. From the Lord Prior of Brampton
AS Parliamentary Under Secretary of State for NHS Productivity (Lords)
A
Department Coa.
of Health

Richmond House
79 Whitehall

Ms C. Henley London
Assistant Coroner SW 1A 2NS
17 Church Street re:
Berwick-upon-Tweed

TD15 1EE 20 JUL 2015

DL He Hes,

Thank you for your letter of 21 May 2015 following the inquest into the
death of Barbara Patterson. I was very sorry to hear of Mrs Patterson’s
death and wish to extend my sincere condolences to her family.

You raise several concerns which relate to the level of ambulance service
which was provided to Mrs Patterson:

. Failure by call handler to give timely advice in respect of CPR.

. The Pathways system piloted in the North East has a fault in that it
does not advise non clinical call handlers to issue CPR advice
unless a patient has stopped breathing. Although this fault was
pointed out to Pathways by NEAS NHS Trust manager before the
latest update of the system (early 2014), Pathways refused to amend
the system. The fault remains in place.

. Failure by ambulance dispatcher to dispatch ambulance closer to
deceased’s location.
° Target time for arrival was 8 minutes but the ambulance took 15

minutes to arrive.

° National shortage of paramedics particularly in the North East

° Ambulance availability is jeopardised by crews being delayed at
hospital when handing patients over to A&E staff.

The most immediate concern is about the lack of timely advice provided
to Mrs Patterson’s family by the ambulance call handler. I understand you
have been told the handler was following the protocol and procedures
from the NHS pathways call handler system (Clinical Decision Support
System (CDSS).

Although Mrs Patterson would not have survived the stroke, you were
told the system did not advise that CPR should be applied on this
occasion, because the patient had not stopped breathing. You consider this
is a fault in the system that needs to be remedied.

NHS Pathways has provided a response to your concerns (attached) which
includes an overview of the CDSS system, how it is implemented,
reviewed and updated and the amendments that are made to supporting
information on breathing assessment. Noisy breathing is already identified
as a major airway compromise that requires an emergency response and
appropriate CPR advice. NHS Pathways believes the call-handler might
have failed to pick up the cues which should have led to this advice being
given.

The target for an emergency ambulance response is that 75% of all Red 1
calls — the most serious, life-threatening category - receive a response
within eight minutes. While ambulance services will always attempt to
provide a response as soon as possible in life-threatening situations, the
target recognises that it is unfortunately not always physically possible for
ambulance services to respond to all Red 1 calls within eight minutes.

The North East Ambulance Service (NEAS) is currently facing
unprecedented demand. NEAS has made progress in recruiting to
vacancies, reducing its paramedic shortfall to 21% at the end of April
2015, and will continue to recruit more paramedics. I understand that
NEAS has separately provided you with its response to the issues you
raised.

To improve services nationally, NHS England’s National Medical
Director, Professor Sir Bruce Keogh, undertook a review of urgent and
emergency care in 2013. This aims to change the way services are
provided, including shifting care outside of the hospital setting where
clinically appropriate, thereby avoiding unnecessary journeys and
admissions to hospital.

The review proposes transforming the urgent and emergency care system
_by:

° providing better support for people to self-care;

° helping people with urgent care needs to get the right advice in the
right place, first time;

° providing highly responsive urgent care services outside of hospital
so people no longer choose to queue in A&E;

° ensuring that those people with more serious or life threatening
emergency care needs receive treatment in centres with the right
facilities and expertise in order to maximise chances of survival and
a good recovery; and

° connecting all urgent and emergency care services together so the
overall system becomes more than just the sum of its parts.

Department
of Health

Some of the proposed changes are already underway, affecting NHS 111,
community pharmacy and developing the ambulance service as a mobile
treatment service rather than solely a transportation service.

Hospital handovers, the process whereby the hospital takes over
responsibility for the patient from the ambulance service, should occur
within 15 minutes of the ambulance’s arrival at the A&E department. The
ambulance crew cannot leave the patient to attend further calls until the
hospital has formally assumed responsibility. There is no single cause for
handover delays and local factors often contribute.

Patient handover therefore needs to be as efficient as possible both to
achieve the best possible outcome for the patient and to free ambulance
resource. Some ambulance services and A&E departments have
introduced Hospital Liaison Officers to act as a single point of contact
between services.

Other work aims to improve the discharge process and patient flow. This
includes reducing delays for patients moving between NHS and social
care organisations so more beds become free. NHS England is preparing
guidance for Urgent and Emergency Care Networks designed to improve
patient flow within the urgent and emergency care system.

Work will continue to increase the number of Physician Associate training
programmes across England in order to meet the workforce needs of
acute, community and primary care providers. HEE will also ensure that
paramedic training provides an additional 16% growth - 1,900 additional
paramedics — in the current workforce over the next five years.

The skills and abilities of paramedics and the wider workforce also need
to be utilised more fully. This will help ambulances to become mobile
treatment services, rather than transport services, so that more patients can
be treated at scene, where clinically appropriate.

We are extending paramedic training to enable them to better assess,
prescribe for and manage patients with chronic illnesses. They need to
work more closely with GPs and community teams. In support of this,
NHS England plans to publish guidance to help ambulance services
develop these new ways of working.

I hope that you find this reply helpful and I am grateful to you for
bringing the circumstances of Mrs Patterson’s death to my attention.

DAVID PRIOR

North East Ambuiance Service

nm Tr

Our ref: HMG/906 Ambulance Headquarters
Your ref: AB/CEH/JT/15/11 Berea Mouse
The Waterfront
23 June 2015 Geldcrest Way
Newburn Riverside
Strictly Private and Confidential Newcastle upon Tyne
Ms Carly Elizabeth Henley NE15 8NY
Assistant Coroner for North Northumberland
H.M. Coroner's Office Tel: 0191 430 2000
17 Church Street Fax: 0191 430 2086
Berwick upon Tweed -
Northumberland
TD15 1EE
By Email: -
Dear Madam,

Re: Ms Barbara Patterson (deceased)

| write with regards to the Regulation 28 Report dated 21 May 2015, which raised a
number of concerns in connection with the inquest touching upon the death of Ms
Barbara Patterson on 02 January 2015 at Wansbeck General Hospital.

Those concerns raised within the Regulation 28 Report are shown below;
1. The failure by the Call Handler to give timely advice in respect of CPR.

2. During the inquest evidence was given that the Pathways system, a computerised
system piloted in the North East and since rolled out for use by 6 other
Healthcare Trusts nationally, has a fault in that it does not advise non clinical call
handlers to issue CPR advice unless a patient has stopped breathing. This fails to
recognise the need for CPR in cases of Aganol (heavy/noisy breathing which is
insufficient to sustain life). This fault was pointed out to Pathways by the Clinical
Section Manager for North East Ambulance Service NHS Foundation Trust. Prior
to the latest update being installed in early 20 14 (Update 9). Pathways refused to
amend the system. That fault remains in place to date.

3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the
deceased’s location.

4. The target time for the arrival of the ambulance was 8 minutes, this was
breached. .The ambulance did not arrive for 15 minutes.

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by
the Care Quality Commission (Provider ID: RX601). For more information visit www.cac.org.uk

5. During the inquest evidence was given that there is a nelioneal shortage of
paramedics, which is particularly acute in the North East.

6. During the inquest evidence was given that ambulance availability is being
jeopardised by crews being delayed at hospital when handing patients over to
Accident and Emergency staff.

| have attached the Trust's resporise to each issue, which you requested by 14 July
2015. As such, the Trust's response repeats the evidence which was given at the
Inquest, based on your comments that you were satisfied with and grateful for the efforts
which the Trust had taken with respect to its investigation and production of
management evidence.

| understand that you were mindful at the Inquest that much of the information to be
included in the Trust's response had already been shared by the Trust in its evidence
disclosed prior to, and considered at, the Inquest.

Finally, | think it is worth highlighting that the national operational standard for
ambulance trusts, as defined within the NHS contract, is for 75% of Red 1 (patients in
respiratory or cardiac arrest) and Red 2 (all other life threatening emergencies) incidents
to be responded to within 8 minutes.

This standard is measured Trust performance as an ambulance provider as opposed to
performance with an individual Clinical Commissioning Group, i.e. Northumberland.

Yours faithfully,

) ‘
ITY ek
a YO new Levon

Yvonne Ormston
Chief Executive

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by
the Care Quality Commission (Provider ID: RX601). For more information visit www.cqc.org.uk