Christopher Fields

ye

Department
of Health

Mr J.S Pollard
Senior Coroner
Coroner’s Court

1 Mount Tabor Street
Stockport

SK1 3AG

i. LL (lewd

From the Lord Prior of Brampton
Parliamentary Under Secretary of State for NHS Productivity (Lords)

Richmond House
79 Whitehall
London

SWIA 2NS

Tel: 020 7210 4850

13 JUL 2016

Thank you for your letter of 19 May 2016, following the inquest into the death of
Christopher Fields. I was sorry to hear of Mr Field’s death and wish to extend my

condolences to his family.

lam aware that the North West Ambulance Service has already responded to your
concerns and I have seen a copy of the reply. However, you are also concerned that the
call to the ambulance service did not generate a red code response time (between 8 and
19 minutes) when the patient was critically injured. You consider that this was because
the algorithms used by the call handlers for coding calls are neither accurate nor fit for
purpose and if not remedied, could lead to future deaths. You ask that the Department of

Health responds to this concern.

NWAS has confirmed that the emergency call concerning Mr Fields was correctly
coded as a Green 2 based on the priority symptoms reported, which at the time of the
call were not critical. The critical injuries to which you refer were sustained following a
second assault some two hours after the first.

Had critical injuries been reported during the first emergency call, different algorithm
questions would have been asked by the call handler and the call would have been

coded with a higher response category.

NWAS use the Advanced Medical Priority Dispatch System (AMPDS) for handling 999
emergency calls. This system determines the priority in which vehicles should be
dispatched based upon the immediacy of the life threatening symptoms displayed by the
patient, as reported by the caller. The call handler then assigns a code for the call which
maps to one of the following response categories below:

Category A calls (life threatening):

Red 1 -8 minutes: Respond to 75% of Red 1 calls within 8 minutes with a suitably
trained and equipped response. This could be an ambulance, a Rapid Response Vehicle
or a community responder .

Red 2 - 8 minutes: Respond to 75% of Red 2 calls within 8 minutes with a suitably
trained and equipped response. This could be an ambulance, a Rapid Response Vehicle
or a community responder .

A19: Respond to 95% of Category A (red 1 & 2 combined) calls within 19 minutes with
a vehicle capable of carrying a patient.

Green calls (serious but non- life threatening):
Green I and 2 —face to face ambulance response within 20 minutes (95% of the time).
Green calls (non-life threatening/non-emergency):

Green 3 - Telephone assessment within 60 minutes (100% of the time) - alternative
pathway referral, upgrade to Red/Green 1 or 2, advice given and call closed.

Green 4 - Telephone assessment within 60 minutes (100% of the time)- alternative
pathway referral, upgrade to Red/Green 1 or 2, advice given and call closed or a
vehicle response within 4 hours

I therefore do not consider that the algorithms used for coding are inaccurate or unfit for
purpose based on the evidence of this case.

However, please note that AMPDS is produced by the Priority Dispatch Corporation, a
private company. If you have concerns about the design of the product you may wish to
contact them direct at the following address:

Priority Dispatch Corporation UK Limited.
Suite B, 4th Floor

Spectrum

Bond Street

Bristol

BS1 3LG

I hope that this reply is helpful and I am grateful to you for bringing the circumstances
of Mr Field’s death to my attention.
UY iy l.

DAVID PRIOR

GREATER MANCHESTER
lan Hopkins QPM., MBA PO L [ E
Chief Constable

Ms Joanne Kearsley
Senior Coroner

The Coroners Court
1 Mount Tabor
Stockport

SK1 3AG a) 04 August 2016

Dear Ms Kearsley

Re: Christopher Philip Fields (deceased)

With regards to the report sent by letter from HMC Mr Pollard dated 18 May 2016 in respect of
Christopher Philip Fields pursuant to Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013 and paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009. |
apologise for the delay in responding as this correspondence was not received into my office
until 16 June 2016. ! reply to the matters you have asked me to consider as follows;

Extract from Requlation 28, point 1. The police were called to the address after the first
assault had occurred and were still in attendance when the assailant re-entered the premises
via the broken window, which he had smashed out of its frame when entering the first time.
Despite this rather bizarre set of occurances, the police then decided to leave the deceased
before the ambulance service arrived. Sometime later, the assailant re-entered the flat and
beat the deceased to his death.

Various issues arise as a result of the police actions, being why did they leave a vulnerable
person in this manner why did they not await the arrival of the ambulance, why did they not
take the witness (female) who was there at the time to a place where she could give them
details out of the earshot of the assailant etc. Why did they leave an injured and/or
intoxicated person in the sole care of another who was also intoxicated, why did they
consider it appropriate to accept the view of the injured / intoxicated person as to whether it
was safe to leave him in the situation in which he was found?

Are there issues of training for all GMP officers or did the officers fail to adhere to the
approved guidance?

No policy or guidance exists that formalises how long officers should wait in such cases and it
would be impractical to set down specific timescales for officers to adhere to. Officers are given
guidance in the use of the National Decision Making Model ((NDMM’). The NDMM allows
officers to make decisions based on the following principles:

Gather information and intelligence

Assess threat and risk and develop a working strategy
Consider powers and policy

Identify options and contingencies

Take action and review what happened

Both Po gave evidence at the Inquest, and provided their rationale with
reference to the National Decision Making Model (NDMM). They assessed that Mr Fields did
not lack capacity to make decisions, was talking calmly and coherently and making his own
choices. Mr Fields wanted the police officers to leave and had (who officers believed were his
friends) with him. He was not giving the officers any information which would allow them to

Postal address. Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d page 2....

progress their investigation. Mr Fields had the telephone number for Stockport Homes and was
capable of speaking to them to speed up the joiner if necessary. A crime report was recorded
at the time in line with national crime recording standards and the officers carried out a primary
investigation. The officers had assessed that although Mr Fields had minor visible injuries they
were not serious or life threatening, however they did feel that he still needed to be assessed by
a medical professional and an ambulance was still required. Following all of this,

judged that there was no policing purpose to justify remaining at the scene.

The officers were interviewed by the said that she believed that the risk to
Mr Fields would be minimised if he had friends with him, and “if | had any indication at all that

were a threat to Christopher | would have stayed with him”. The officers
stated that they were influenced by Mr Fields stating that he was “fine” in the presence of the
two persons. The IPCC investigator's opinion was that both i made
appropriate dynamic assessments about the extent to which Mr Fields had any welfare needs
and required safeguarding, based on_his injuries, his ability to meet his own needs and his
behaviour whilst in the company — and The officers also based their
assessment on Mr Field's limited response to their questions and him wanting the officers to
leave the flat.

was spoken to by the officers as a potential witness and had given conflicting
accounts. She initially denied any knowledge of the incident. [ENN had confronted her with
information that a female had been seen running away, and she told the officer that she had
called for the ambulance, but did not know who was responsible. Mr Fields as the victim, was
taken to one side away from the two persons present in the address and spoken to privately,
being asked what had occurred, who was involved and if he wanted the other two people
removing. Mr Fields told the officers that they could remain as they were all friends.

The crime and incident recording procedure states that the investigation should be victim
focused. Appendix D of the Incident Response policy states that the victim’s needs and the
investigation must be at the forefront of all decisions.

A check on previous incidents at the address would not have assisted with any decision to
arrest, as there was a long history of alcohol related incidents involving Mr Fields and other
persons.

The IPCC noted that neither officer challenged HR account or actions; she said she
was asleep at the flat at the time of the assault but Mr Fields was adamant no women had been
at his flat. They also state that the officers missed the opportunity to ask if GE was
actually [J to at least establish his identity in light of the information from the house to house
witness. However, the officers checked for signs of injury or bloodstains on his clothing
and found none, to which HMC acknowledged this as “the officers took the precaution of
checking the knuckles of J and satisfied themselves that there was no evidence of injury
such as might be expected from someone who had recently been involved in a fight”.

asked the male who presented as [EN if he might in fact be IJ which was denied.
Moreover, the police were told repeatedly by Mr Fields that J was not the person who had
assaulted him, and that he was his friend.

Both officers gave clear, unambiguous evidence that they did not consider to have been
the perpetrator, and in such circumstances there would be no grounds for an arrest. The Police
and Criminal Evidence Act 1984, requires for a lawful arrest when there are reasonable grounds
for suspecting a person's involvement or attempted involvement in the commission of a criminal

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d page 3....

offence and reasonable grounds for believing that the person's arrest is necessary. On the
information available to the officers at the time, there was insufficient evidence of involvement in
a criminal offence by any of those present at the scene. This was also accepted by HMC,
summing up ‘I find that there was insufficient evidence upon which the officers could reasonably
be expected to have arrested the mar {a

In relation to the learning that has arisen out of this case, was given management
action for the lack of documentation within his pocket note book. Errors in recording inaccurate
information was addressed in the witness evidence of ) Operational
Communications Branch Business Lead at Inquest.

It is proposed that we will be able to report back to the Coroners. In October 2016 in terms of
the wider work we are completing around vulnerability, including the lessons learnt from this
case.

Yours sincerely

|

lan Hopkins
Chief Constable

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

INHS|

England

Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
Joanne Kearsley SE1 6LH
HM Acting Senior Coroner
1 Mottram Street
Mount Tabor
Stockport

SK1 3PA 1* September 2016

Dear Ms Kearsley,
Re: Regulation 28 —- Christopher Philip Fields

| refer to the Coroner's Regulation 28 Report concerning the death of
Christopher Philip Fields and | would like to express my deep sympathy to Mr
Fields’ family.

The Report outlined three concerns with only the following point identified as
being potentially relevant to NHS England:

3. The fact that the call taker coded the call properly and yet this case
involved a patient who was clearly critically injured and despite that fact it
still did not generate a Red response, suggests that algorithms used for
coding are not accurate and not fit for purpose. In my view this is an
extremely serious flaw and may/will tead to future deaths occurring unless
it is remedied. (NWAS, Secretary of State, NHS England).

{ note the response from North West Ambulance Service (NWAS), letter dated 10
June 2016, confirming that the initial ambulance call was correctly coded as
Green 2 because the deceased was conscious, breathing and able to walk at that
time. It appears from the limited material in my possession to have been the
second assault that inflicted critical injuries and proved fatal, as indicated by the
Pathologist's report.

NWAS uses the Advanced Medical Priority Dispatch System (AMPDS), an
internationally recognised system developed and accredited by the international
Academies of Emergency Dispatch, and tested on many millions of 999 calls in
the United Kingdom and overseas. Whilst AMPDS is generally regarded as fit for
purpose, it can never be 100% accurate because it relies heavily on the accuracy
of the information supplied by a caller, and to a lesser extent on the interpretation
of ambulance call handling and dispatch staff. The Coroner may appreciate that
these human elements are vulnerable to individual error.

NHS England is currently leading a complete review of ambulance coding
systems and trialling a new system. This review will take into account both the
High quality care for all, now and for future generations

outcome of previous similar 999 calls as well as the concerns raised by Coroners.
in Regulation 28 Reports. We anticipate making recommendations in autumn
2016. It is our intention that this review should improve the service provided and
clinical outcomes for future patients contacting the 999 ambulance service.

Thank you for bringing this matter to my attention.

Yours sincerely,

Brut \C

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations

—

GS North West Ambulance Service AHS)

“és NHS5 Trust
OUR REF: Headquarters
INQ/C/GM/15/413 Ladybridge Hall
aimeerreo1204 399 Chorley New Road
3 Heaton, Bolton
498 444 BL1 5DD

www.nwas.nhs.uk

HM Senior Coroner John Pollard
Coroners Area of Manchester South
2 Mottram St

Stockport

SK1 3PA

10 June 2016
Dear HM Senior Coroner Pollard

Re: Inquest into the untimely death of Christopher Philip Fields
Date& Time of hearing: Monday 11™ April to Thursday 14" Aprit 2016
Location: Stockport Coroners Court

Matter: PFD Regulation 28 Report

Thank you for your letter dated 19 May 2016 which encloses a copy of the Regulation 28 report
issued against NWAS, pursuant to paragraph 7, Schedule 5 of the Coroner's and Justice Act 2009
and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013.

{ note your specific concerns centre around the following:-

‘2. The calls (999) to the ambulance service were properly coded and applied by the cail taker
leading to a Green 2 response. This should have led to the vehicle attending within 20 minutes. In
the event, the vehicle did not arrive for 2 hours 8 minutes. Why was the response time so
dramatically lengthier than prescribed and is this a matter of resources? (NWAS)

3. The fact that the call taker coded the call properly and yet this case involved a patient who was
clearly critically injured and despite that fact it still did not generate a Red response, suggests that
the algorithms used for coding are not accurate and not fit for the purpose. In my view this is an-
extremely serious flaw and may/will lead to future deaths occurring unless it is remedied. (NWAS,
SECRETARY OF STATE and NHS ENGLAND).

Taking each point in turn, | confirm that the vehicle response time for the incident in question, was
inextricably linked to the activity pressures, NWAS faced during this extremely challenging winter
period. Despite winter weather contingency planning, activity within the Greater Manchester area
saw an unexpected 22% increase, which was directly compounded by significant hospital
turnaround pressures faced at Stepping Hill, North Manchester and Oldham.

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

The wider NHS reported similar pressures and it is recorded that Yorkshire Ambulance Service
declared a Major incident at 14:30 due to the volume of work they faced on the date in question.

It should be noted that Green 2 response times are ‘as soon as practicable’ and whilst NWAS
strives to attend these types of incidents as soon as practicable, due to the challenges faced on
the date in question, the response time was regrettably longer than we would have hoped.

NWAS is currently exploring better ways to minimise lengthy waits during high demand periods
and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope
will assist in alleviating some of these pressures.

In regards to AMPDS system, | confirm that based on the priority symptoms given during the 999
call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s
chest had been ‘concaved in’ this would have directly affected his respiratory system and been
captured during the breathing algorithm question, resulting in a higher response. | note that the
attending police officers evidence supported that the patient was breathing, conscious and able to
walk, when they attended the scene, shortly after the first call which supports that the patient’s
condition, at that time was not time critical, requiring an 8 minute response (life sustaining
treatment). Furthermore this assertion was reinforced by RIE > sth olozist report which
supported that the critical injury was sustained during the second assault.

| hope you will accept that these are very difficult issues to resolve, with no quick fix solutions, but
continued efforts are being made to consider better ways of managing these challenging periods.

If you do have any further concerns or questions please feel free to contact me.

Kind regards

Head of Legal Services