Ronald Volante

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

RESPONSE OF MAGENTA LIVING TO CONCERNS OUTLINED PURSUANT TO REGULATION 28:
REPORT TO PREVENT FURTHER DEATHS — MR.VOLANTE

In the case of Mr Ronald Volante

Background

Magenta Living delivers a Community Alarm monitoring service to our own tenants and as in
the case of Mr. Volante, to other local housing associations that do not provide their own
monitoring services directly. The service is a non-statutory housing related service aimed at
pramoting independent living within a home setting. It is accredited by the TSA (Telecare
Services Association) which is the national body against whose standards we are assessed.
Magenta Living does not provide a visiting warden’s service to this scheme.

CORONER’S CONCERNS

1, Magenta Living Support Link had access to Mr. Volante’s medical history and there
is no evidence that this was used to advise the ambulance service of his cardiac
problems - is this covered in the induction training of call handlers

Current practice

Hitherto the approach has been that once through to the Ambulance Control Centre the
community alarm operator is taken through a set of standard questions by the Ambulance
Service operator. These questions are designed to elicit sufficient information in respect of
the address, location, access arrangements and the condition of the person concerned and is
used by the Ambulance Service to prioritise calls. This is reflected in Magenta Living’s
written procedure, which is provided to all call handlers as part of their training, which
states in relation to “Requesting ambulance attendance”, that “if requested by the
ambulance service controller, the call handler shall provide such additional information as
they have in respect of the incident and the building.”

Proactively providing medical history to the ambulance service at the point of initial contact
by call handlers was not covered in induction training for call handlers. This does not form
part of the procedure accredited by the TSA. The procedure was established in the context
that the ambulance service is in a better position to assess what information is and isn’t
relevant. In Mr Volante’s case, the Magenta Living call handler followed procedure and
answered the questions posed to him by the ambulance service controller and no details
regarding medical history were requested. Had the ambulance service controller requested
such detail, and they were in the position to assess whether medical history was relevant,
our call handler would have provided the information

Response to Coroner’s concerns

Following the concerns raised at the inquest and subsequently detailed in the Regulation 28
Report to Prevent Further Deaths Notice we have revised how we will deal with calls to the
Ambulance service. We have written to all of our community alarm customers, including
those organisations with whom we have contracts to provide a similar service. We have
confirmed that with immediate effect that there will be an addition to current procedures in

so far as we will share medical details at the point of contact with the emergency services
unless service users specifically advise us otherwise.

As a result of this change of procedure, all Magenta Living community alarmed trained call
handlers were briefed with effect from 28" January 2016 as to this change and provided
with a copy of the updated procedure that now includes this additional stage. As part of this
discussion, staff confirmed their understanding of the new procedure which is recorded in
their training record. This change of procedure will also be addressed with any new staff as
part of their normal induction programme.

Additionally, as part of our commitment to improve service standards, we have liaised
directly with the TSA and discussed in detail the concerns raised by the Coroner. Whilst the
TSA reaffirmed that there is currently no national requirement to share medical information
with the emergency services, the TSA has confirmed their intention to review the relevant
parts of their Code of Practice. The TSA has indicated that they aim to introduce measures
to ensure that the provision of medical history to the ambulance service is embedded within
the Standards Framework within the Code of Practice as national practice in the future.
Upon receipt of the amended Standards Framework from the TSA, we will provide a copy to
the Coroner.

2. Magenta Living Support Link were aware that there had been a change in Mr.
Volante’s presentation by 18:46 as he did not respond to the news that an
ambulance was on the way —is this covered in induction training of call handlers
with regard to advising a doctor or emergency service of a change in circumstances
after the first call

Current practice

Historically, a change of circumstances would not result in a call handler updating the
emergency services. To provide context this is because of the way the contact centre is
connected to the sheltered housing scheme. The contact centre is connected to each
scheme via a telephone line which allows the call handler the ability to speak with a resident
who has activated the alarm as well as being able to control the communal door entry
system to the block of flats. When an alarm is activated by a resident, the call would be
closed down once the next of kin or ambulance service had been notified and as such a
change of circumstance would not necessarily be evident. This practice was adopted due to
the fact that keeping the line open could potentially impact upon our ability to respond to
further activations from residents at the same scheme and to provide remote access to the
emergency services when they arrive through the communal door entry system.

Response to Coroner’s concerns

In light of the Coroner’s concerns, all Magenta Living’s community alarm call handlers have
been briefed with effect from 28" January 2016 that they should update the emergency
services of any change in the client’s circumstances / presentation as soon as these are
known. To achieve this and to take into account the resource pressure experienced by the
North West Ambulance Service and the impact upon their response times, we have now
adopted a policy whereby a call handler will maintain regular contact with the resident until
their key holders (next of kin) or emergency services arrive. This change of practice has
been updated in our revised procedure. It is hoped that this approach will provide support

to the North West Ambulance Service and assurance to those affected by delays in respect
of ambulance response times.

As detailed above, all Magenta Living community alarmed trained call handlers have been
briefed in respect of this change and provided with a copy of the procedure that now
includes these additional stages. As part of the discussion, staff confirmed their
understanding of the new procedure which is recorded in their training record. This change
of procedure will also be addressed with any new staff as part of their normal induction
programme.

3. The training manual and method of training call handlers needs to be revisited in
light of the experience from Mr. Volante’s tragic death

Current practice

Magenta Living’s has a thorough, comprehensive training and induction programme which is
accredited by the TSA. Individual performance is regularly monitored through work reviews,
team meetings, auditing and quality assurance, coaching, external auditing (for accreditation
purposes), contract monitoring and customer feedback.

Response to Coroner’s concerns

However, in light of the Coroner’s concerns and appreciating that standards can always be
improved, Magenta Living has incorporated a number of additions to the procedures manual
as a result of the Coroner’s recommendations as set out above. Our standard practice,
which has been followed in respect of these changes, is that any changes or amendments
made to procedures are always quickly communicated to staff across the various shifts. This
is carried out on a one-to-one basis and also at team level. For assurance purposes, Team
Leaders and managers ensure staff implement any changes smoothly and effectively and
measures are put in place to monitor this such as spot auditing, listening to call recordings,
data checks. Any concerns are immediately brought to the attention of the member of staff
and a performance improvement plan is established. This may include for example further
coaching, side by side monitoring and peer support until an acceptable performance level is
attained. As a learning organisation, training for Magenta Living community alarm handlers
is continuous and this approach will continue.

DATED 23 MARCH 2016