William Nute

South Western Ambulance Service INHS|

NHS Foundation Trust

Trust Headquarters

Abbey Court
PRIVATE & CONFIDENTIAL cay
TO BE OPENED BY ADDRESSEE ONLY Devon
Dr Emma Carlyon — HM Senior Coroner EX2 7HY
The New Lodge Tel: 01392 261500
Penmount Fax: 01392 261510
Newquay Road Website: www.swast.nhs.uk
Truro
TR4 9AA

Sent via recorded delivery and secure email to

25" July 2016:
Dear Dr Carlyon
Prevention for Future Deaths report - Mr William Nute

| write further to receiving your report under Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, following the inquest into the death of Mr William Nute.

In your report, you set out the circumstances of Mr Nute’s death and identify some
concerns you feel were not fully addressed during the Inquest earlier this year. | will
endeavour to deal with each point raised in turn.

In terms of the delayj ic crews attending Mr Nute, it is acknowledged in the
report compiled | (Senior Dispatcher), a copy of which was submitted
in evidence for the inquest, that a 999 call was received at 11.45 on 30" June 2015. As
indicated in the report and indeed during the hearing, it appears there was initially some
confusion on scene as to whether Mr Nute had been hit by a reversing car travelling at

slow speed, or whether he had simply fallen.

Once it had been confirmed to the call handler that the bystanders believed he had been
hit by the car, a Rapid Response Vehicle (RRV Solo Responder) was allocated to attend
at 11.50. The disposition reached was a Green 2, with a target response time of 30
minutes. Furthermore, a Double Crewed Ambulance (DCA) vehicle was also dispatched
at 11.52.

Unfortunately, | understand both the RRV and DCA were stood down because they were
diverted to higher priority calls i.e. Red 2 8 minute response patients, who may not have
been conscious or breathing and so were time critical. Following a second 999 call at
12.16 and reports of a deterioration in Mr Nute’s symptoms, the disposition was
upgraded to a Red 2 8 minute response. A RRV was subsequently allocated at 12.21
and arrived on scene at 12.35.

It is accepted that the first response on scene was some 50 minutes after the call was
received and 20 minutes outside of the target response time. However, once on scene,
the Emergency Care Practitioner (ECP) was able to provide Mr Nute with the care and
interventions required immediately. During this time he completed four sets of

observations, he cannulated, and administered IV morphine, 1 g paracetamol and 250 ml
saline to Mr Nute. He completed most of the Patient Clinical Record, including the C-
Spine assessment at 12:50 and recorded injuries (left hip) and mechanism of injury. In
addition, he recorded the airway, breathing, circulation and disability (neurological)
assessments. He has also completed a Major Trauma assessment, the conclusion of
which was to convey to a Trauma Unit.

After conducting an initial assessment of the patient, the ECP made a request for priority
2 back-up at 12.40, after being on scene for 4 minutes. Regrettably, a DCA was not
immediately available, as all resources were committed. The next available conveying
resource was therefore allocated at 13.12 and arrived on scene at 13.44.

It is recognised by the Trust that waiting for a resource equipped to transport a patient to
hospital for 2 hours would have been very distressing and uncomfortable for Mr Nute and
for this we are truly sorry. However, it is important to bear in mind that ambulance
services nation-wide are faced with resourcing difficulties and are required to send
resources to the most time-critical patients as calls are received. It is important to
remember that whilst it was not possible to convey Mr Nute to hospital as quickly as we
would have liked, an ECP was on scene with him and providing him with essential care
from 12.35.

As outlined in HE port, at the time of the original call, activity was reported as
being 20% above the predicted level, which consequently impacted on the availability of
resources to attend.

In terms of the concerns received regarding a delay in conveying Mr Nute to hospital, a
review of our systems has confirmed that the crew left scene at 14.55 and arrived at the
Royal Cornwall Hospital Trust at 16.14, with a journey time of 1 hour and 20 minutes. |
understand the crew encountered a couple of difficulties with the vehicle on the way to
hospital which meant they had to stop on a couple of occasions for a few minutes. | am
advised, however that the crew took the quickest route to the hospital which would
ordinarily take 1 hour 5 minutes. This meant there was a delay to hospital but only by 15
minutes.

In terms of the question as to whether the call received was triaged appropriately, | can
confirm thal investigation confirmed that the disposition reached for the
original call was indeed correct. An audit of this call was undertaken as part of the
investigation, which confirmed the call achieved 97% compliance against a pass rate of
86%.That said, it is acknowledged that the police were not notified of the incident until
12.56, an hour after the original call had been received. | am aware that concerns were
raised during the inquest that the delay in notifying the police could have led to the driver
of the vehicle leaving the scene and furthermore, placed a responsibility on those
members of public on scene to effectively shield Mr Nute from passing traffic. It is
acknowledged that a police presence may have also served to reassure both Mr Nute
and the public that matters were in hand.

It is therefore accepted that the police should have been notified once it had been
confirmed that there had been a road traffic collision, as per the Trust’s Standard
Operating Procedure, a copy of which is enclosed for your ease of reference. You will
note that to ensure call handlers are able to focus on answering emergency calls, the
responsibility for making the call rests with the dispatcher. It is, however, important that
the requirement for police is made clear by the call handler when recording the details of
the call on the screen, as this is the information used by the dispatcher to make decisions

regarding the allocation of resources etc. The need to call the police for assistance forms
part of dispatcher’s daily role and is one they are all acutely familiar with.

It appears the failure to inform the police in a timely way on his occasion could be
attributed to human error. It is possible that this was, in part, due to a lapse
communication but may also be due to how busy the service was that day. While it is not
possible to identify a reason on this occasion, | wish to make it clear that as a service, we
work alongside Devon and Cornwall Police on a daily basis and although problems will
always be encountered due to the volume of calls received, on the whole we work
together very effectively and maintain strong levels of communication.

In an attempt to ensure we work to continuously improve our working relationship with
other emergency services, including Devon and Cornwall Police, representatives from the
Trust attend a number of different meetings which provide a platform for any issues or
concerns to be discussed and addressed. These include:

Emergency Services Forum

This is a meeting to discuss collaborative working and specifically how systems and
processes can be improved.

Blue Light Collaboration

This is to discuss operational issues and pressures as well as future initiatives.

Frequent Caller Forum

This is a newly set up meeting to manage the above.

Blue light meeting

This is attended by a Trust representative to discuss issues and incidents that have been
raised between the respective organisations with a view to agreeing how these might be
addressed and resolved.

| can also advise that there is a Memorandum of Understanding between South Western
Ambulance Service Foundation Trust (SWASFT) and the police services covering the
same region which has been in place since 2013. The purpose of this document is to
formalise the agreed working practices of those involved and seeks to underpin any
localised arrangements already in place. Further, it sets out the expected level of service
to be delivered by both SWASFT and the police at a local level.

In terms of what is being done to address the nation-wide resourcing difficulties faced by
ambulance services, | can advise that in early 2015, Sir Bruce Keogh was asked to
review NHS performance standards to ensure they make sense for patients and are
operationally well-designed. This included those targets within the ambulance service,
where in some cases, vehicles were being dispatched in order to “stop the clock” rather
than serve the best interests of patients. This type of incentive was leading to the lower
availability of ambulances for some urgent patients.

Since this review, NHS England has formed the Ambulance Response Programme
(ARP) to conduct a clinically led and evidence-based review of the current call coding

systems. Professor Jonathan Benger, National Clinical Director for Urgent Care has led
this work which aims to achieve three things:

1) Making sure our sickest patients get the fastest response. For example those in or
near cardiac arrest get the nearest vehicle;

2) Where possible, to send the most appropriate vehicle to meet the patient's clinical
needs first time e.g. stroke patients need a conveying double crewed ambulance rather
than a rapid response car. This is because a key part of their care is to have a scan in
hospital to see if they require thrombolysis.

3) Where clinically appropriate, look to increase the number of patients we treat, or
signpost onto the correct service. In short, it's about improving the way we manage 999
calls to better meet the definitive clinical needs of the patients, rather than currently
focusing on time targets.

ARP has now developed a new call coding set which has been trialling in two sites -
South Western Ambulance Service NHS Foundation Trust and Yorkshire Ambulance
Service for a minimum of 12 weeks since April 2016.

ARP is working with academic partners at Sheffield University’s School of Health and
Related Research (ScHARR) to oversee the process. The trial is monitored by an
operational group chaired by the Association of Ambulance Chief Executives (AACE),
reporting to the ARP Expert Reference Group and Steering Group. This work has also
been shared with our national stakeholder group, including patient and public
representatives.

| trust the above response addresses your concerns raised in your report in full but
should you require any further information, please do not hesitate to contact me.

Yours sincerely,

Uy buy.

Ken Wenman
Chief Executive

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Chairman: Heather Strawbridge