Jane Reason

British Heart
Foundation

HM Senior Coroner

Birmingham and Solihull Areas Greater London House
Coroner’s Court 180 Hampstead Road

50 Newton Street London NWI 7AW

Birmingham T+ 020 7554 0000
B4 6NE F+ 020 7554 0349
W' bhf.org.uk

By email and by post

16" December 2016

Dear Mrs Hunt,

Your ref: 114060 — JANE LOUISE REASON (LH/RP)

Response to the Regulation 28 Report to Prevent Further Deaths issued by the Senior Coroner’s
Office for the Birmingham and Solihull Areas dated 25 October 2016

Thank you for your letter dated 25th October 2016 enclosing your Report to Prevent Further Deaths
in this very unfortunate matter. As Director of the Prevention, Survival and Support Directorate for
the British Heart Foundation (BHF) | have been asked by our Chief Executive, Simon Gillespie, to
respond on behalf of the BHF to the Matters of Concern raised in your report.

We acknowledge and fully support that improved awareness and accessibility of public access
defibrillators would be of significant benefit in preventing similar unnecessary deaths. The
importance of the general public having the confidence to deliver cardiopulmonary resuscitation
(CPR) and use a defibrillator in an emergency is core to the work of the BHF. We are grateful for the
opportunity to respond on this matter as part of your investigation into this issue.

The BHF is a company limited by guarantee, incorporated in England on 28 July 1961, and with a
registered office at Greater London House, 180 Hampstead Road, London NW1 7AW. It is a
registered charity in England and Wales (charity number 225971) and in Scotland (charity number
SC039426).

The purposes for which the BHF is established (i.e. its charitable objectives), as set out in its Articles
of Association, are:

“‘wuto attack and defeat diseases and conditions of the heart and circulation and other
diseases, illness or conditions, by undertaking and promoting research for the public benefit
into their cause, diagnosis, treatment and prevention, promoting their diagnosis, treatment
and prevention, educating the public and alleviating suffering and promoting the welfare of
persons afflicted and those who care for such persons.”

FIGHT FOR EVERY HEARTBEAT

bhf.org.uk

Patron HRH The Prince Philip KG KT : A Company Limited by Guarantee. Registered in England Number 699547 Head and Registered Office at 180 Hampstead Road, London NWI 7AW
Chief Executive Simon Gillespie : Telephone 020 7554 0000. The British Heart Foundation is a registered charity in England and Wales (225971) and in Scotland (SC039426)

The BHF can only carry out activities that fall within its charitable objectives, but it is not under a
legal duty to carry out any particular activity that may fall within these objectives either by statute or
otherwise, unless it contractually agrees to do so. Like all charities, its overall purposes must be to
the benefit of the public.

Since it was established in 1961, the BHF has powered critical advances in heart health, from
pacemakers to statins. Cardiovascular disease kills more people in the UK than all cancers put
together and the BHF funds over half of all cardiovascular research in the UK.

With regards to the Matters of Concern we recognise that immediate access to a defibrillator is a key
part of the chain of survival in ensuring more people survive from out-of-hospital cardiac arrest.
There are more than 30,000 out-of-hospital cardiac arrests in the UK each year and currently less
than 1 in 10 people survive. This is partly because many people don’t have the skills, confidence and
ability to step in and help. Around 80% of out-of-hospital cardiac arrests happen in the home which
is why CPR skills and defibrillation awareness are so important. In instances of an out-of-hospital
cardiac arrest, calling 999, immediate CPR and access to a public access defibrillator (PAD) are
essential to maximise the chances of survival indeed, all are essential parts of the chain of survival
which are the internationally recognised set of steps to increase the chances of survival for someone
who’s had a cardiac arrest. Effective CPR means that the casualty is more likely to be kept in a
shockable heart rhythm and this coupled with the placement of PADs in public places helps to
reduce the time delay between cardiac arrest and shock from the defibrillator and time is an
important factor. PADs are specifically designed to be used by members of the public as well as first
responders in the event of a cardiac arrest and no training is required as they have spoken
instructions and won't deliver a shock unless necessary.

The BHF is committed to tackling the low out-of-hospital cardiac arrest survival rates in the UK by:

¢ increasing the rate of bystander CPR by providing free CPR training kits to schools and the
general public; and

¢ increasing the rate of bystander PAD use by increasing awareness, availability and visibility
of PADs.

The BHF has a clear five year strategy to 2021 and we are currently investing time, money and
resources in a number of projects to improve survival rates from out-of-hospital cardiac arrest.

Training resources
Making CPR training more accessible, the BHF has a programme called Call Push Rescue which is a

unique self-directed learning kit that is free to eligible secondary schools and community groups.
There are currently over 2300 secondary schools and over 1800 adult and youth community groups
who are part of this programme. We are also working with partners including Scotland and Greater
Manchester fire and rescue services to support CPR training in schools and local communities.
Furthermore the BHF works with a number of corporate partners, BHF retail shops and workplaces
to offer CPR training to employees. We are continuing to support our 2000 existing Heartstart
schemes who teach a more in depth first aid course covering choking, bleeding and CPR skills and
this has meant the BHF has helped to train over 1.6 million people since 2014.

The BHF has been a key partner in running national awareness campaigns about the importance of
bystander CPR skills on “European Restart a Heart Day” for 3 years and have recently worked with a
number of partners including the UK Resuscitation Council, British Red Cross, St John Ambulance and
the 14 UK ambulance services to provide resources and support training of 150,000 young people in
one day at a number of events across the UK on 18th October 2016.

Improving accessibility and availability of PADs

The BHF provide part funding to community groups to enable them to purchase a PAD for their local
area and have awarded 435 PADs already in 2016 and we are currently managing and distributing
the £1,000,000 PAD funding project awarded to the Department of Health from the treasury budget
in 2016 which will provide more PADs to local communities in England. The BHF are working closely
with the UK Resuscitation Council to redesign the signs for PADs in order to improve visibility and
increase bystander use in public access areas.

There are currently an unknown number of PADs across the UK (the figure is estimated to be
100,000) and importantly there is no central database which captures information regarding the
location of these PADs for the UK ambulance services. If emergency call responders at the
ambulance service were able to locate the closest defibrillator via a national database then they
could direct a bystander to the PAD and this may impact on improving survival rates. The BHF are
investing funds to review options to develop a National PAD database, which would be accessible
to all ambulance services and make locating the PADs much easier.

Research

The BHF provides grant funding for a UK wide out-of-hospital cardiac arrest registry at Warwick
University which will support audit of service improvement. The BHF and its partners have
developed a series of initiatives to try to improve bystander CPR and PAD use, but how effective
these projects are is not known. The Out of Hospital Cardiac Arrest Outcomes project at Warwick will
collect information to work out the best ways of improving the bystander response to cardiac arrest.
We also have links with other countries in Europe and with hospital specialists to further develop our
understanding of the best ways to improve survival from cardiac arrest.

Key collaborations
The BHF are convening expert advisory groups with representation from the four nations to improve

out-of-hospital cardiac arrest survival rates through a system wide approach and we are part of a
number of key collaborations. The BHF are working with the NHS & Welsh Government to develop
an out-of-hospital cardiac arrest strategy in Wales, We have been supporting the Community
Resuscitation steering group in England chaired ie develop a national
framework document “resuscitation to recovery” to improve care of people with out-of-hospital

cardiac arrest in England. BHF are a member of the Scottish Government Out of Hospital Cardiac
Arrest strategy delivery group which aims to improve survival rates in Scotland.

In conjunction with the Resuscitation Council we have recently developed “A guide to Automated
External Defibrillators” which provides information about PADs and how they can be deployed in the
community to help resuscitate victims of sudden cardiac arrest.

Genetic Information Service

In addition to significant funding in medical research into inherited heart conditions that can cause
sudden death, we have also invested in implementing the research finding in clinical practice so that
families affected by an inherited heart condition can receive the appropriate care quickly. We also
provide a Genetic Information Service for families affected by inherited heart conditions and support
families where a diagnosis of an inherited heart condition has been made in a living or a deceased
family member. Coroners are also encouraged to call the Genetic Information Service for advice if
they suspect an individual has died due to an inherited heart condition and need advice on how to
refer the surviving family members for treatment. To date we have had two meetings with the Chief
Coroner for England to raise awareness of the service amongst coroners and coroners’ officers.

In summary we are actively engaged in providing access to training resources to teach CPR skills and
PAD familiarisation on a range of programmes and provide access to funding for PADs but we have
no authority to carry out these programmes as a matter of public policy as we are not a government
institution or public authority. However, the BHF recommends that all young people are given access
to CPR training and defibrillator awareness while at secondary school and would ask that you
support this recommendation by communicating this to the Department for Education.

We hope that the information provided above sufficiently clarifies the BHF’s position with regards to
the Matters of Concern raised. Should your office require further explanation the BHF is more than

happy to offer its assistance in any way.

Yours Sincerely,

Director — Prevention, Survival and Support
On behalf of the British Heart Foundation

2016-0059995POS0S

o
ng oD”
TMENT FoR EOYS

Rt Hon Justine Greening MP
Secretary of State

Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT

tel: 0370 000 2288 www.education.gov.uk/help/contactus RECEIVED

Mrs Louise Hunt 20 FEB 2017
HM Senior Coroner, Birmingham & Solihull Districts
Coroner's Court BY:
50 Newton Street

Birmingham

B4 6NE

Your ref: 114060

{4 February 2017

Deo Mrs Yunk ,

Thank you for your letters of 25 October 2016 and 26 January, and for
providing me with sight of the Report to Prevent Future Deaths following the
inquest of Ms Jane Louise Reason. Unfortunately, your first letter seems to
have been lost due to an administration error — | am terribly sorry for the delay
in my reply.

| was extremely saddened to hear about the circumstances of Ms Reason’s
death. | read the Regulation 28 Report with great care. | agree that every
consideration must be given in order to prevent, so far as we possibly can,
tragedies of this nature occurring in our schools, colleges and other education
institutions. | assure you that the safety and wellbeing of staff, and of those in
their care, is a matter that my department takes very seriously.

My department published a guide on automated external defibrillators in
April 2016, which is available at: tinyurl.com/zn82vva. Since this tragic
incident, we have published new guidance that is more relevant to further
education colleges. | shall be writing to the Association of Colleges to draw
this guidance to the attention of their members.

Thank you for writing on this important matter.
ere Walar,

RT HON JUSTINE GREENING MP

RECEIVED
19 DEC 2016

INHS)

England

Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
Mrs Louise Hunt SE1 6LH
HM Senior Coroner — Birmingham &
Solihull
Coroner's Court
50 Newton Street
Birmingham
B4 6NE 14" December 2016

Your ref: 114060 - JANE LOUISE REASON (LH/RP)

Dear Mrs Hunt,

Thank you for your letter and report dated 25 October 2016. | was very sorry to
read of the circumstances around Jane’s death, and would like to express my
deep condolences to the Reason family.

Out of hospital cardiac arrest (OHCA) is common, affecting over 50 000 people
in England annually. The chain of action which optimises chances of survival
starts with an early call for help and bystander cardiopulmonary resuscitation
(CPR), both of which occurred in this case. Early defibrillation where indicated is
also part of that chain of command. We are unable to comment on why
defibrillation appeared to be indicated but was not delivered by the initial
ambulance crew member.

Subsequently, a second ambulance crew arrived and a defibrillation shock was
administered but this delay reduced the chances of successful defibrillation. This
was then further compounded by the battery failure of the second defibrillator.
Why there was battery failure is unclear as defibrillators should be fully charged
and checked daily. We are aware of an alert for Lifepak defibrillators where
premature battery failure has led to an alert, but it is not clear whether this
defibrillator was of that make. The ambulance services will be able to answer the
issues we are unable to clearly respond to above.

Professor Huon Gray, NHS England National Clinical Director for Cardiac
Diseases, has stated that we agree of the need for (a) more public access
defibrillators (PADs) and (b) increased training in CPR. Both will increase the
chances of survival from OHCA in public places.

A. Programme for “PADs”
The Treasury has allocated £2m of public money to purchase and

distribute more PADs. £1m has already been allocated and the second
£1m should be available in the next 3-6 months. Both tranches have been

High quality care for all, now and for future generations

overseen by the Department of Health and distributed by the British Heart
Foundation (BHF).

B. Increased Training

The Department for Education has given written guidance to schools
encouraging training in CPR and availability of PADs in schools. The Fire
Service are promoting both CPR and WSome schools do have Automated
external defibrillators (AEDs) too and train staff in CPR.

| hope the above has provided some reassurances that NHS England has taken
your concern on board

Yours Sincerely,

coc.

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

High quality care for all, now and for future generations

ry, Resuscitation Council (UK)

HM Senior Coroner
Birmingham and Solihull Areas
Coroner's Court

50 Newton Street
Birmingham

B4 6NE

16.11.2016

Dear Mrs Hunt,
Your ref: 114060 — JANE LOUISE REASON (LH/RP)

Thank you for your letter dated 25'" October 2016 regarding your Report to Prevent Future Deaths in
this sad case. We agree that it is appropriate that further action should be taken to prevent future
deaths in relation to the availability of public access defibrillators (PAD), often referred to as an AED
(Automated External Defibrillator), and thank you for giving us the opportunity to respond.

The Resuscitation Council (UK) (RC (UK)) is a charity established by medical professionals to promote
high-quality practice in all aspects of cardiopulmonary resuscitation (CPR) and improve survival rates
from cardiac arrest. The charity exists to promote high-quality, scientifically-based resuscitation
guidelines that are applicable to everybody, and to contribute to saving life through education,
training, research and collaboration.

In relation to your requirements, we recognise that immediate access to a defibrillator is key to
improving the chances of survival from cardiac arrest for many individuals. This can be achieved
through greater numbers of PADs in the community, knowledge of the location of these devices and
resuscitation training for the public. This will help to ensure the public have the knowledge and
confidence to give basic life support (BLS) and use a PAD when appropriate. This is a message that we
have been promoting for some time and continue to do so with enthusiasm.

To this end we are engaged in the following activities:

e Education
We recognise education facilitates many of the aims of the RC (UK). We work closely with UK
ambulance service, other first aid organisations and the European Resuscitation Council to
encourage all members of the public to learn first aid (BLS and AED use). In the UK, we have
recently organised the annual ‘European Restart a Heart Day’ which through hundreds of
events that took place across the UK, trained over 150,000 children and young people in basic
life support.
We have been campaigning at all levels to make BLS and AED teaching mandatory for all
school children. Although disappointingly we have not managed to make this a mandatory
part of the school curriculum, our campaign has undoubtedly raised the need for this training
and improved the numbers of school children who are taught these vital life skills.

e Training
The RC (UK) runs a number of immediate and advanced life support courses which help
promote the wider need for awareness of defibrillators in public places, training
approximately 150,000 medical professionals each year.

5" Floor Tavistock House North, Tavistock Square, London, WC1H 9HR_-—_ Telephone (020) 7388 4678 Fax (020) 7383 0773
Email enquiries@resus.org.uk Website www.resus.org.uk

Registered Charity Number 286360

vy, Resuscitation Council (UK)

e Guidelines
The RC (UK) is a contributor to international and European resuscitation guidelines from which
are distilled the UK resuscitation guidelines. We work with key first aid organisations (e.g.
ambulance service, RNLI, St John etc.) to ensure that recommendations relating to bystander
CPR and defibrillation are disseminated as appropriate throughout the entire UK.
Additionally, in conjunction with the British Heart Foundation, we have recently published ‘A
guide to Automated External Defibrillators’ which is designed to provide information about
AEDs and how they can be deployed in the community to help resuscitate a victim of sudden
cardiac arrest.

e Research
The RC (UK) funds a number of research projects relating to resuscitation and in particular
defibrillation that contribute to our knowledge and use of AEDs.

e Improving the availability of AEDs
We are currently working with the Department of Health to oversee the distribution of
£1,000,000 funding for public access defibrillators across communities in the UK.
After extensive public consultation, we have redesigned the signage to be used for all PADs in
order to improve the visibility of the devices and increase their use at cardiac arrests in public
areas.

e Collaboration
We regularly work with statutory and non-statutory organisations where we share common
aims in order to promote the use of PADs. We have been contributing a major project with the
Department of Health to produce a national framework to improve the treatment of patients
with cardiac arrest (Resuscitation to Recovery: A National Framework to improve care of
people with Out-of-Hospital Cardiac Arrest (OHCA) in England. 2016) This document makes
specific recommendations with regards to improving availability of PADs.

In summary, whilst being actively engaged with the above requirements, we have no power to
mandate these. We would ask that your recommendations are shared with the Department of
Education, in particular that all children are trained in BLS and defibrillator awareness as a mandatory
part of the curriculum.

We hope that this letter clarifies our position with regards to placement of PADs and educating the
public and hope that it meets your requirements.

Yours sincerely,

On behalf of the Resuscitation Council (UK)

5 Floor Tavistock House North, Tavistock Square, London, WC1H 9HR-__ Telephone (020) 7388 4678 Fax (020) 7383 0773
Email enquiries@resus.org.uk Website www.resus.org.uk

Registered Charity Number 286360