Colin Sluman

INHS|

England

(Our Ref: CJS reg 28 NHS England
Your Ref: CJS reg 28) 4th floor, South Piaza
Marlborough Street

Bristol

BS1 3NX

Email address —

Telephone Number — 0113 8248335

Date: 10th August 2017
Dr Elizabeth Earland
HM Senior Coroner for the County of
Devon
Exeter & Greater Devon Coroner's
Office
Room 226
Devon County Hall
Topsham road
Exeter EX2 4QD

Dear Dr Earland

Re: Colin James Sluman DOD 15.07.2016. Inquest held on the 7“ June
2017 at South Molton Town Hall Regulation 28 Report

Thank you for your letter dated 21°' June 2017. As requested please find
enclosed our substantive response to your concerns.

Matter of concern 1) In respect of the protocol supplied by NHS Pathways to
South Western Ambulance Service NHS Trust (SWAST), we can confirm that on
15" February 2017 the Clinical Lead of SWAST wrote to NHS Pathways
regarding consideration into whether the triage tool (NHS Pathways or Trust
procedures) should prioritise incidents taking into account a patient that is on
their own, particularly when they have a major haemorrhage and are showing
signs of shock.

In addition to this, the Clinical Lead of SWAST raised with NHS Pathways
concerns surrounding dizziness symptoms not being part of the “major
haemorrhage” triage pathway and whether it should be included.

In relation to the queries concerning the content of NHS Pathways, a Lead
Clinical Author at NHS Pathways stated that the level of blood loss experienced
by Mr.Sluman was such that it generated a 19 minute ambulance response. This
is the same level of response as would have been generated by a patient in
probable clinical shock, i.e. cold, clammy and centrally cyanosed. The addition
of a question about dizziness would therefore not have raised the disposition
level.

The question of raising the level of response because the caller is alone is a
complex one which is dependent upon a wide range of factors. These
considerations have always been assessed operationally on a case-by-case
basis by organisations using the NHS Pathways system.

On the 20" July 2016 a local amendment was also implemented. This highlights
to clinicians in the clinical hub that patients presenting with “Major Blood Loss”
(without other symptoms) should be reviewed by a clinical supervisor at the
earliest opportunity.

On the 19" June 2017 all actions on the action plan developed from the Root
Cause Analysis Investigation Report were reviewed.

Matter of concern 2) In respect of call handlers not being clinically trained, they
are reliant on the software provided (in this instance Pathways) and therefore it is
felt that the response from NHS Pathways regarding Matter of Concern 1 should
address this concern.

Additionally, in relation to the use of the system by non-clinically trained call
handlers, the content and the disposition levels of the NHS Pathways system is
overseen by its National Clinical Governance Group (NCGG). This group is
chaired by RCGP and members include all clinical colleges (medical/surgery,
nursing/midwifery, paramedics), key stakeholders including patients, services
(NASMeD and NHS 111) and pharmacists. The pathways themselves are under
constant review, and are revised in response to any changes in guidance (e.g.
NICE Guidance), published evidence or any incidents related to use of the
system.

All call handlers using NHS Pathways undergo an intensive training programme
that spans 10 weeks. This programme incorporates several fornial training
modules focusing on NHS Pathways use, distance learning materials, supervised
practice, consolidated practice and a ‘common learning programme’. This
common learning is a wider training and development programme ensuring all
staff are fully prepared and competently skilled for their role delivering care in the
NHS. It includes sessions such as customer service skills, managing vulnerable
callers and management of calls with a mental health component.

Throughout the training period, there are several competency gateways that staff
must pass through successfully to progress to independent practice. This
includes written assessments, practical assessments and call audits during
supervised practice. Once call handlers start practising independently they are
then subject to on-going performance management and professional
development as set out in the NHS Pathway licence.

Matter of concern 3) In respect of there not being enough clinical supervisors
available to call handlers for advice or oversight of emergency calls, this is being
addressed by SWAST increasing the clinical supervisor workforce by 10
Clinicians across all Clinical Hubs. Also, work is being conducted within SWAST
to look at “clinical oversight” and how best to accomplish this within the resources
available.

| hope this information is helpful however if you require any further information
please do not hesitate to contact me.

Yours sincerely

Quality & Safety Manager
NHS England, South (South West)

CC , NHS South, Central and West Commissioning Support Unit
NHS Pathways

INHS

South Western

Ambulance Service

NHS Foundation Trust.

Your ref: EAE/RB 1670-2016

Trust Headquarters.
31 August 2017 petra
Exeter
i i Devon
Private & Confidential epeven

Senior Coroner
Dr Elizabeth Earland
Exeter and Greater Devon Coroner's Office

Tel: 01392 261500
Fax: 01392 261510

Room 226, Website: www.swast.nhs.uk

Devon County Hall,
Topsham Road,
Exeter,

EX2 4QD

Dear Dr Earland
Prevention for Future Death Report- Colin Sluman

We write in connection with the Inquest touching on the death of Mr Colin Sluman and in
response to a Prevention for Future Deaths Report issued to the Trust in accordance with
Sch 5 (Coroners and Justice Act 2009 and reg 28 and 29 of the Coroners (Investigation)
Regulations 2013.

The report identified three chief concerns, which we will address in turn:

(1) The protocol supplied by NHS Pathways to SWAST call handlers does not
include reports of ‘dizziness’ and ‘patients on their own’ as important triggers
for a rapid response to a report of catastrophic haemorrhage

Upon making the call to the ambulance service, Mr Sluman explained to the Emergency
Medical Advisor (EMA) that he was bleeding from the back of the leg. The EMA selected a
‘Nature of Call’ category, that is, they identified from a list the nature of call that best fits
the description of what happened to the patient. In this case, the nature of the call was
‘bleeding’ and accordingly it was this that indicated the likely urgency of the call, although
the final urgency was not determined until the triage was complete.

As a Pathway had now been identified, the Emergency Medical Advisor began to triage Mr
Sluman using the triage tool- NHS Pathways. Depending on the Pathway selected, a
series of questions devised by clinical experts and designed to assess the appropriate
urgency and type of response required, is generated. The EMA is tasked with asking each
question as scripted within the triage system and must select an appropriate response
using the supporting information available. As non-clinicians, the EMAs are prohibited from
deviating from the questions and are encouraged to ask them as they appear on the
screen to ensure the clinical meaning of the question is accurately conveyed.

It is, however, the final urgency of the call that determines the category of response
assigned to the incident. In this case, the full NHS Pathways triage process resulted in a
disposition of ‘emergency ambulance response for major blood loss’ - Amber (R). This
indicates that a blue light resource was needed, with a paramedic or autonomous clinician
on board.

The questions generated by this Pathway did not include questions relating to dizziness
nor did they prompt Mr Sluman to confirm whether he was alone. However, as Mr Sluman
had informed the EMA towards the end of the call that he felt dizzy, the EMA felt this was
relevant and decided to make a note of this on the system. As explained in her statement,
the EMA felt comfortable that an appropriate disposition had been reached- that is, an
emergency response with an indicative response time of 19 minutes. The EMA also
confirmed that she knew that in the event of delay, it would be important for a clinician
reviewing the records to be aware of this to ensure they could make an informed decision
regarding any required escalation of the call. The EMA explained in her statement that she
recognised that this call was very serious and attempted to consult a clinician once the call
had ended.

At the time of the incident, an Amber (R) disposition was the second highest emergency
response category and had a locally set target response time of 19 minutes. Other
conditions likely to be assigned an Amber (R) disposition would include: Myocardial
Infarctions, strokes and sepsis, which meant that the highest response category- Red calls
would be reserved for those patients who were not breathing or conscious at the time the
call was received. It is therefore important to bear in mind that the role of an EMA is to
triage 999 calls before passing the responsibility for allocating a resource to the
dispatching team. Whilst this does not negate their duty to alert clinicians to a call they
have concerns about, it is their responsibility to ensure they answer 999 calls and so once
the call had ended, the EMA in this instance would have been required to continue
answering 999 calls rather than monitoring the adherence to a target response time.

Following the incident, concerns regarding the bleeding Pathway were quickly identified
and escalated by the Trust's Clinical Lead to NHS Pathways for consideration. The
concern as to whether a question relating to dizziness should be incorporated within the
bleeding Pathway was first raised on 15" July 2016. The Serious Incident investigation
report highlighting these concerns was also shared with their organisation in December
2016. Itis the Trust's understanding that NHS Pathways has considered the concerns
raised and do not feel that the addition of a question about dizziness would have raised
the disposition level.

In terms of whether the fact that Mr Sluman was alone when he made the call was
considered when triaging the call, again this is not a question that is contained within the
Pathway and was not volunteered by Mr Sluman during the call. As explained above,
EMAs are not permitted to deviate from the questions generated by the Pathway to ensure
the required responses are elicited from the patient and an appropriate disposition is
reached that is based on clinical presentation. However, in the event a patient advises an

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EMA that they are alone, it would be good practice for the EMA to note this information on
the log, as this might assist a Clinician tasked with reviewing the call.

The Trust does, however, operate a Welfare Call Standard Operating Policy (SOP),
whereby if it is not possible to allocate a resource to a patient within the indicative
response time, a call is made to check on a patient's welfare and reassess their clinical
condition if necessary. At the time of the incident, the Welfare Call SOP in place, ‘Ensuring
patient safety at times of high demand’ required a call following an Amber (R) disposition
to be made at the time the incident breached its waiting time and for a Clinician within the
Clinical Hub to endeavour to contact the patient every 60 minutes until a response arrived
on scene. In this case, the time of breach was 01.56. No welfare call was made at that
point due to the workload demand in the Clinical Hub. At 02.40, a Clinical Supervisor
became available and attempted to make a Welfare Call to Mr Sluman. Sadly there was no
response, and so the Clinical Supervisor made the decision to upgrade the call to a
Red/Amber, which means it would be prioritised over other outstanding amber calls.

The Trust has carefully reviewed the Welfare Call Standard Operating Procedure (SOP)
and is developing a new process tailored to meet the needs of the patients waiting for an
ambulance to arrive. The focus of the new process moves away from a standard time
based approach to making welfare calls which are patient centred and clinically driven.
The new procedure starts with an early review of calls by a registered clinician who will, if
indicated by the information gained through the triage, or if demand is likely to cause a
delayed response, contact patients to conduct a more thorough clinical review. This will, in
turn, inform any decisions to adjust the disposition and the timing of any further welfare
calls required.

.2) Call handlers are not clinically trained and are completely reliant on the protocol
for categorising responses

The Emergency Medical Advisors (EMAs) answering calls for the 999 service are not
clinically qualified. They do, however, receive intensive training in the operation of the
triage tool utilised in the Clinical Hub in which they are based. In this instance, the EMA
was working from the South Clinical Hub in Exeter, where NHS Pathways is the triage tool
utilised. Before the EMAs are permitted to take 999 calls, they are required to engage ina
twelve week induction programme. The course materials are designed by NHS Pathways
and although the course is delivered by facilitators employed by the Trust, these
individuals are also trained by NHS Pathways.

The twelve week induction programme commences with three weeks of classroom
learning, during which time there are three written assessments that must be completed. if
these assessments are not passed, the candidate cannot continue with the training. On
completion of the classroom learning the trainees will progress on to an eight week
mentorship of supervised call practice, taking 999 calls. These calls are taken with either
the training team or experienced Pathways 'coaches'. In the final week of the mentored
call taking, the trainee will need to pass call audits undertaken by the Quality and
Improvement team. These audits need to be passed for the candidate to continue with the
training. On completion of these audits the trainee will need to complete a final classroom

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based assessment. Failure to pass this assessment will result in the candidate failing to
pass the training. After successfully passing the induction training, the EMA's performance
will be regularly audited and furthermore, they are required to complete all NHS Pathways
updated training modules.

In terms of whether EMAs are completely reliant on NHS Pathways to reach a disposition,
as the Pathways are meticulously devised by a panel of clinical experts, EMAs are for the
most part, able to rely on the disposition reached. However, there are occasions where
the Trust does not consider a particular disposition (as would be generated by NHS
Pathways) for a specific patient presentation to be appropriate despite being clinically safe.
On those occasions, the issues are escalated to NHS Pathways for review. Although the
Pathways may be revised as a result, if change is not felt to be clinically necessary, it is for
the Trust to determine whether local guidance or SOPs should be implemented to govern
a particular situation and accordingly any policies would need to be ratified through internal
governance procedures.

EMAs and EMDs (Emergency Medical Dispatchers) are able to access any guidance or
SOPs affecting their working practices on their administrative computers, together with
guides to explain any particular practices to be utilised.

Furthermore, in the event an EMA identifies a call as being complex, that is where a
patient is presenting with multiple symptoms or the EMA feels the scope of the call is
outside their experience level, the EMA can refer the call to a clinician for advice. A
clinician is then able to review the call and the disposition reached to determine whether it
is appropriate. A clinician is permitted to exercise their clinical judgement to upgrade the
disposition where necessary and may decide to undertake an enhanced triage, that is a
further consultation to inform their decision. In the event a clinician is not available to
review a call, an EMA should escalate their concerns to more senior members of staff and
ultimately to a Duty Manager, who is also able to upgrade a call.

Local guidance is also disseminated to EMAs with a view to educating them regarding any
topical issues or red flags associated with particular conditions that may arise during a
telephone triage. This enables EMAs to be alert to the clinical significance of symptoms
raised, which may prompt them to seek clinical support during a call.

3) There not being enough Clinical Supervisors available to call handlers for advice
at all times nor do they have constant oversight of emergency calls.

It is acknowledged within the Trust’s Serious Incident report that Mr Sluman stated he was
feeling dizzy towards the end of the call and that it would have been appropriate for the

EMA to seek advice from a Clinical Supervisor, as this symptom is not covered within the
Pathway questions.

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In her statement, the EMA explained that following the termination of the call, she looked
on the internal telephony system to see if a Clinical Supervisor was available, in order to
make them aware of the call but explains that none were available. !n this circumstance,
the expectation would have been for the EMA to have documented this on the incident log.
Furthermore, options such as placing a ‘warning on’ alert with her concerns to a non-
clinically qualified dispatcher were not utilised by the EMA. The aim here would be for the
warning to be considered by the dispatcher, who could then consult a Clinical Supervisor.
The EMA has reflected on this incident considerably and has explained in her statement
that she would ensure this is documented in the future.

One of the actions recommended following the completion of the Serious Incident report
was to increase the clinical support within the clinical hubs to meet the increasing demand.
In response, funding was put in place to recruit an additional ten clinicians. A review of the
clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to
the time of day etc.

In terms of whether there is sufficient clinical support available to EMAs, South Western
Ambulance Service Foundation NHS Trust operates its 999 service from two clinical hubs-
one in Bristol (North Hub) and one in Exeter (South Hub). In addition to call handling staff
employed to answer the 999 calls and dispatching staff, the Trust also employs registered
Health Care Professionals including: nurses, paramedics, General Practitioners and
midwives to support call handling and dispatch functions. The Trust has a minimum of four
clinicians on shift per hub but averages between 6 and 10 clinicians in each Hub,
excluding GP and midwife support. The exact number depends on the time of day and the
day of the week.

Clinicians based within the Hub are tasked with: reviewing calls awaiting a response,
providing telephone consultations and advice to patients, support to operational staff and
are also pivotal in the management of frequent callers. Clinicians within the Hubs will be
designated to certain work-streams during their shift to ensure as far as possible, an
oversight of emergency and non-emergency calls. For example, in the South Hub, the core
clinical staffing requirement is four. Of the four, one will be assigned to support the
dispatchers. They are responsible for looking through the waiting emergency calls to
identify those that may be of particular concern and those that may require alternative care
pathways. They will then add those calls into the Clinical Support Desk queue, where they
are then prioritised according to a timer so that the clinicians working from this queue will
know which are the most urgent to review and upgrade where required. Another clinician
will be assigned to Category 1 calls (the highest category response) to provide emergency
pre-arrival advice and two clinicians will work on the Clinical Support Desk queue and log
in to be available for EMA/EMD support. Any additional clinicians on duty will also work
from the queue.

The Clinical Hubs utilise different triage tools (which was a consequence of the acquisition
of Great Western Ambulance Service in 2013); the South Hub using NHS

Pathways and the Bristol hub using MPDS for call handlers and PSIAM for clinicians. The
Trust is, however, currently looking to implement a single triage system to align the
working practices of both hubs.

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In response to continual increases in call volume, the Trust has implemented a virtual
telephony system to ensure an available call handler, irrespective of location, will take a
999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical
support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are
able to seek clinical support from available clinicians irrespective of their hub location,
thereby maximising the clinical support available to call handling staff.

A further system utilised by clinicians within the hub is the Escalation Report. This is a tool
on the administrative computers on each Clinical Supervisor's desk and is designed to
assist clinicians to identify incidents that have been triaged to an ‘Amber’ disposition but
may be in need of a higher level of urgency. It only includes those incidents where an
ambulance has yet to be allocated and relates to those categories of call that have the
potential to be life-threatening, as in this instance. A Clinical Supervisor can then review
the incidents highlighted by this report and decide whether to call the patient for further
triage and upgrade the call where required. Before this incident, ‘major blood loss’ (without
other symptoms) did not appear as a category identified on the Escalation report.
However, as a direct result of this incident, ‘major blood loss’ (without other symptoms)
has been added to the Escalation Report and is also joined by other ‘major blood loss’
categories including ‘ major blood loss, non-trauma and shock’.

In providing you with a comprehensive response to the points raised within the report, we
hope we have been able to provide both you and the family of Mr Sluman with assurance
that the issues raised have been taken very seriously and acted upon. If we can be of any
further assistance, please do not hesitate to contact me or the Claims and Inquests team.

Yours sincerely

ouWanr

Ken Wenman
Chief Executive

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