Darren Powney

Private and Confidential 

Mr Derek Winter 
Senior Coroner for the City of Sunderland 
Civic Centre  
Burdon Road 
Sunderland 
SR2 7DN 

10th January 2018 

Dear Mr Winter   

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Tel:  0191 430 2000 
www.neas.nhs.uk 

Ref: YO/AG/HMC1320 

Inquest into the death of Mr Darren James Powney (Deceased) 

Response  of  the  North  East  Ambulance  Service    NHS  Foundation  Trust  (NEAS)  to  the 
Regulation 28 Report to prevent future deaths 

I am writing in my role as Chief Executive of NEAS and further to your Regulation 28 Report for the 
prevention  of future  deaths  dated  10  November 2017  as  issued following  the  Inquest  into the  tragic 
death of Darren which commenced on 6 November 2017.   

In your report, you highlighted the following concerns: 

“Although  a  lot  of  work  has  been  done,  I  am  concerned  there  appears  to  me  more  to  be  done, 
implemented  and  trained  upon  sooner,  rather  than  later.  Nearly  a  year  on  and,  although  the  new 
protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a 
clear  training  programme.  In  any  event  I  hope  my  Report  will  give  the  necessary  impetus  to 
conclusion and implementation”. 

The Trust will address each point you have raised in your matters of concern below. 

Use of caution and information 'Flags'  

During the inquest 
 provided written and verbal evidence to explain that the Trust uses 
a  number  of  sources  to  add  information  'flags'  to  patients'  addresses.  The  evidence  included  the 
procedure titled 'Adding and Reviewing ‘Caution’ Flags for Violence and Aggression Procedure'. This 
sets out the process for violence and caution flags to be placed on to the system without delay and 
ensure that, crews have information available to them regarding any potential risks to their safety.  

Temporary  flags  added  by  NEAS  staff  are  reviewed  within  3  months,  which  allows  time  for  a  full 
investigation. All flags are, however, reviewed as soon as possible to validate their appropriateness. 
As  detailed  in  the  aforementioned  procedure  exhibited  at  the  inquest,  the  review  date  for  flags  will 
usually be after 6 or 12 months of the date of the incident which prompted the flag, unless otherwise 
arranged. The process for reviewing the flags includes a number of clear steps and can result in an 
extension  or  removal  of  a  flag.  In  this  case  I  am  aware  that  the  flag  was  reviewed  and  deemed  to 
remain appropriate,  

It is clear from this case that the information contained in the flag was used in isolation to inform the 
crew of potential concerns, without accessing additional information or attending the scene to conduct 
a more robust dynamic risk assessment. 

Chairman: Ashley Winter | Chief Executive: Yvonne Ormston 
The North East Trust NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 In order to address this we have ensured that when a crew does not feel safe to proceed and access 
a property, without police support, based on the ‘flag’ this is then escalated to the Clinical Operation 
Manager or the Assistant Services Manager on duty so they may review all information available and 
speak directly to the crew on scene. 

When  such  a  situation  occurs  we  will  ensure  an  incident  report  is  logged  to  enable  a  constructive 
conversation with the appropriate senior staff within NEAS and the Police. It will also enable the Trust 
to look at themes and trends relating to this situation. 

As  part  of  the  organisational  restructure  we  have  reviewed  how  we  manage  Special  Patient  Notes 
and  have  appointed  a  team  focused  on  this  and  ‘Frequent  Callers’. We  are  currently  reviewing  our 
existing Standard Operating Procedures, which will be completed by March 2018.    

Joint Operating Procedure review  

As  confirmed  at  the  inquest,  there  is  a  Joint Operating  Procedure  (JOP)  between  the Trust  and the 
three local Police forces. The aim of the JOP is to provide guidance to the Police in relation to when 
the Trust will attend to provide medical assistance and to provide guidance to the Trust in relation to 
the powers and responsibilities the Police have in responding to incidents involving medical matters.   

As  discussed  at  the  inquest  and  as  a  result  of  Darren's  death,  the  JOP  was  reviewed  by  Alan 
Gallagher,  the  Trust's  Head  of  Risk,  and  Chief  Superintendent  Sav  Patsalos,  of  the  Northumbria 
Police  as  it  was  identified  that clarification  was  required  regarding  who  should  attend  patients  when 
the  risk  assessments  of  the  two  services  differ.  This  has  resulted  in  the  creation  of  an  escalation 
process  which  was  incorporated  into  the  JOP.  This  enables  a  review  of  all  information  available, 
oversight  of  the  situation  and  prompt  action.  Any  cases  where  this  situation  has  occurred  will  be 
reported  via  the  Trust  incident  reporting  system and  will  be  brought  to the  attention  of the  Strategic 
Head of Operations.    

To provide assurances I can confirm that since the inquest the escalation process has been followed 
by our staff and it has been successful. One example was a case which was escalated to a Clinical 
Operations  Manager.  A  Clinical  Care  Manager  was  subsequently  deployed  to  support  a  crew  at 
scene. This matter was resolved without incident or delay and provided direct support and learning for 
the  staff  involved.  Since  the  introduction  of  the  escalation  process  we  have  not  encountered  any 
negative impact on staff or patient safety 

The Trust has continued to work with the 3 local Police Forces to promote and develop the JOP. The 
most current version of the JOP is version 14 and includes an update in light of the new Ambulance 
Response  Programme  (ARP)  which  replaces  previous  language/terms  with  the  new  ambulance 
categories.  The  Trust  can  confirm  that  the  changes  are  simply  relating  to  ambulance  response 
categories. The main content remains unchanged from that shared at the inquest. A copy of the latest 
JOP is enclosed.  

The Trust can confirm that the JOP is currently being used by the stakeholders and will continue to 
evolve as part of the Trust's collaborative work with Police colleagues. Whilst the JOP has not as yet 
been  formally  collectively  launched,  plans  are  being  made  for  the  various  Executive  teams  to  meet 
and  jointly  sign  the  current  version.  The  dates  suggested  for  this  meeting  commence  on  the  6th 
February 2018 with partners being asked to provide availability. The plans also include a joint media 
launch  so  the  work  can  be  publically  shared  to  show  the  on-going  collaboration  between  the 
emergency  services.  The  Trust  would  however  like  to  assure  you  that  this  is  more  of  a  ceremonial 
matter linked with promoting our collaboration. As stated above all three Police Forces and the Trust 
have agreed the JOP and use it in our daily routines. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Improved awareness and understanding of the JOP by frontline staff 

It was apparent that we needed to ensure our communication to frontline staff regarding the JOP was 
more robust and following the inquest dedicated time was spent with the paramedic crew involved in 
the case to reflect and learn from this incident. 

We have undertaken a range of measures to ensure staff understand the JOP and how it applies to 
them in practice as follows: 

•  Staff  briefing  –  a  briefing  document  (entitled  “Reducing  demand  on  police  and  ambulance 
service  Briefing")  was  cascaded  onto  staff  using  the  Trusts  electronic  alerts  system,  which 
enables monitoring of staff receiving the document. (see enclosed) 

• 

•  Memorandum – in order to reach every member of staff working in the frontline we have sent 
(entitled  "Caution  Markers/Flags  and  Dynamic  Risk  Assessments 
a  memorandum 
Memorandum") signed by the Chief Operating Officer, Head of Risk and a member of Unison. 
This was circulated using our electronic alerts system. (see enclosed) 
Internal publication (The Pulse) – a specific update has been written regarding the JOP and 
will be published in the January edition, scheduled for circulation in January. 
Information  and  instruction  –  we  recognise the  important role  Clinical  Operations  Managers, 
Clinical Care Managers and Assistant Services Managers (Dispatch) have in operationalising 
the JOP and have therefore held face to face sessions led by the Head of Risk to ensure they 
are familiar with the JOP / dynamic risk assessment process.  

• 

•  Meetings  –  The  Head  of  Risk  has  attended  meetings  with  Emergency  Operations  Centre 
managers to ensure the JOP has been discussed with call handlers, dispatch staff and those 
working in the Clinical Hub.  

•  Phased  roll  out  of  the  updated  JOP  –  this  was  led  by  the  Head  of  Risk  and  enabled  true 

engagement and discussion with key staff 

•  Assurance  –  we  have  a  process  of  ‘Ride  Outs’,  where  the  Clinical  Care  Managers  observe 
the  practice  of  our  front  line  staff  in  the  Emergency  Service,  and  included  as  part  of  this 
assurance process is a discussion with the staff member regarding dynamic risk assessment 
and  the  JOP.  ‘Ride  Outs’  are  performed  on  a twelve  week  roiling  program,  depending  upon 
service pressures. 

• 

•  The Emergency Operations Centre staff have monthly 1:1’s with their line manager whereby 
feedback  on  the  knowledge  of  the  call  takers,  dispatch  staff  and  clinicians  of  the  JOP  / 
dynamic risk assessment has been reviewed.     
Incident management – reporting and investigating incidents relating to incidents where police 
do  not  agree  with  the  risk  assessment  to  support  crews  on  scene  will  be  managed  by 
operational  managers,  in  line  with  the  Trust  Incident  Reporting  policy.  Oversight  of  themes 
and trends will be undertaken by the Risk Department and the Head of Risk will feedback key 
findings to the Police to support the refinement of the JOP. 

•  New staff – from January 2018, as part of local induction the need to cover the JOP / caution 
markers  and  flags  /  dynamic  risk  assessment  is  identified  for  call  takers,  dispatch  staff, 
clinicians,  frontline  crews,  Clinical  Care  Managers,  Clinical  Operations  Managers  and 
Assistant  Service  Managers  (Dispatch)  to  ensure  they  are  aware  and  familiar  with  the 
procedures  in  place  to  keep  patients  and  themselves  safe.  Completion  of  local  induction  is 
monitored by the Organisational Development Dept.          

Dynamic risk assessment 

Undertaking a dynamic risk assessment is central to the work we do in delivering safe patient care as 
an Ambulance Trust. In order to reinforce to front line crews key areas to consider when informed that 
there is a flag relating to possible violence and aggression, a sticker has been developed to be placed 
in the front of the vehicle with prompts to consider prior to requesting police support.  
Following agreement with the relevant departments this is currently being produced and will be in all 
vehicles by the end of March 2018. 

3 

 
 
 
 
 
 
 
 Operational  crews  receive  conflict  resolution  training,  breakaway  training  and  dynamic  risk 
assessment  training  as  part  of  Statutory  and  Mandatory  training,  this  also  includes  use  of  the  joint 
decision making model. The Trusts data currently shows that 88% of operational staff have received 
statutory and mandatory training.  

The main element of the risk assessment is conducted on scene by operational staff. In this case the 
crew  felt  attendance  posed  a  high  risk  due  to  the  numerous  caution  flags  held  on  the  system.  This 
intelligence was provided by Northumbria Police. The Trust has a specific policy covering this area as 
well  as  standard  operating  procedures.  The  flags  are  presented  to  crews  via  the  vehicle  Terrafix 
system and/or verbally onto rapid response when travelling to scene.  

THRIVE training plan  

The  Police  use  a  THRIVE  assessment  model  (Threat,  harm,  risk,  investigation,  vulnerability  and 
engagement)  to  assist  in  prioritising  whether  a  situation  is  a  high,  medium  or  low,  with  associated 
actions  relating  to  each  level.  In  order  to  support  collaborative  working  based  on  a  shared 
understanding the Trust has embarked on a programme of equipping Emergency Operations Centre 
(EOC)  staff  with  an  understanding  of  this  model  and  how  it  can  be  used  in  practice.  THRIVE  is  a 
model aimed specifically at EOC staff and not operational staff. 

All staff have received a briefing in relation to the Joint Operating Procedure and THRIVE. Information 
is also accessible on the internal communications site (Lamp) for EOC staff. Specific training on the 
THRIVE process is planned for remainder of the financial year with a target to deliver this for 75% of 
EOC staff by end of March 2018. Further training will then be incorporated into our training plan. 

Originally THRIVE training was planned to commence earlier in 2017/2018; this was however delayed 
due  to  the  need  to  work  with  Northumbria  Police  to  create  a  NEAS  specific  package.  Delivery  was 
further delayed due to previously planned priority mandatory training such as NHS Pathways updates, 
Safeguarding and more recently the National Ambulance Reponses Programme (ARP). Subsequently 
the Trust has planned to focus on this training during November and December, unfortunately due to 
the  extreme  pressures faced  over  this  period  it was  not  possible  to  provide  the  training.  During  this 
time the Trust was operating between level 3 and 4 on the Resource Escalation Action Plan (REAP), 
see enclosed REAP plan. 

The  main  reason  NEAS  have  introduced  this  training  is  to  align  knowledge  across  emergency 
services  so  we  can  understand  their  calls  grading  process.  In  essence  we  will  use  this  to  consider 
factors alongside the NHS Pathways triage. 

We are making arrangements to discuss with Police colleagues whether shared THRIVE training with 
Police and Ambulance operations centre staff may add further value to improve shared understanding 
of  roles,  services,  pressures  and  constraints  in  order  to  build  on  the  positive  and  collaborative 
relationships between the Emergency Services..       

Review of ‘frequent callers’ procedure 

It was discussed at inquest that Darren had called for an ambulance on 21 occasions from May 2016 
– December 2016. The Trust has reviewed the standard operating procedures we have for managing 
frequent callers, and the drafts are currently out for consultation, with a plan to have these approved 
by March 2018.  

The Special Patient Notes team will also oversee the Frequent Caller activity and be responsible for 
implementing the updated SOP’s, when they are approved.  

We have tested our flagging system to provide assurance that it is highlighting ‘frequent callers’ and 
are establishing a wider internal multi-disciplinary group, to include patient safety and safeguarding to 
review cases and refer on to primary care for case review / Multi-disciplinary Team involvement. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 Staff safety   

We  are  committed  to  keep  our  staff  safe,  wherever  possible  and  we  are  trialling  ‘Body  Worn"’ 
cameras.  These are devices which will be worn by our operational staff members and the trial is to 
commence  in  early  2018.    The  Trust  will  look  at  the  feedback  and  review  whether  the  use  of  the 
cameras has had an impact on reducing violence and aggression against staff.    

Further collaboration with the Police 

The Trust has a number of other initiatives with its neighbouring Police forces. These all fall under the 
banner  of  ‘joint  demand  reduction’,  the  overarching  aim  being  collaboration  across  the  region.  The 
initiatives include meetings at Chief Officer level, a senior management group and working groups to 
implement change. Elements of the work being undertaken include; 

  Direct access for operational staff into each control room i.e. Police can call the Trust's control 
room  directly 
for 
advice/assessment. In the event of a serious incident direct contact between control rooms will 
also occur; 

the  Trust  can  call  Police  control 

for  medical  advice/triage  and 

  A  forcible  entry  agreement  being  in  place  between  the  Ambulance  service,  the  Fire  service 

and the Police; 

  The  Trust  provides  support  for  Clinical  Governance  arrangements  within  Northumbria  Police 
and  for specialist units (firearms and public order teams) within Cleveland Police and Durham 
Constabulary; 

  Existing information/intelligence sharing agreements; 
  Existing  Safe  Haven  (an  alcohol  reception  facility)  in  Newcastle  city  centre  with  Northumbria 

Police; 

  Ongoing joint  operations for  periods  of  high  demand, (e.g.  the  Christmas  period  – Operation 

Ginger) etc.; 

  Joint road safety campaigns with the Police and Fire services; 
  Trust meetings with the Police innovation lead; 
  Joint  working  on  mental  health  projects  involving  the  Police  service,  the  Trust  and  Mental 

Health Trust; 

  Joint safety work for major exercises; 
  Joint  training  exercises  such  as  the  recent  marauding  terrorist  firearms  attack  (MTFA)  held 

across the region, i.e. Operation Custodian at the Metro Centre.  

  We  are  in  the  process  of  arranging  the  re-printing  and  re-issuing  of  the  advice  cards 
previously  issued  to  the  Police  following  the  introduction  of  ARP.  The  local  Fire  and 
Rescue  Services  and  some  Street  Pastor  services  have  also  requested  copies  of  these 
cards; 

  Other  Police  forces  have  requested,  and  received,  a  copy  of  the  JOP  to  assess  local 

implementation. 

These initiatives have already provided a number of benefits, including a reduction in demand upon 
each emergency service due to improved understanding and improvements in the formal processes 
that  are  followed.  For  example  police  colleagues  would  be  provided  with  a  30  minutes  ambulance 
response for all requests, unless a life threatening case. Since the introduction of the JOP these calls 
are triaged to ascertain the most appropriate level of support. This in itself has reduced the time spent 
on  scene  by  police  officers  waiting for  an  ambulance  which  was  often  not  necessary. This  has also 
reduced the number of queries raised by the police if officers on scene for prolonged periods of time, 
when in fact it was not appropriate to allocate an ambulance response. 

The  reduced  demand  allows  an  improved  response  time  for  all  stakeholders  attending  appropriate 
cases.  These  initiatives  also  ensure  that  resources  are  appropriately  used,  through  improved 
collaboration and staff/public safety.  

5 

 
 
 
 
 
 
 
 
 
 Conclusion 

In summary I can confirm the following: 

  The Trust and Police colleagues have implemented version 14 of the JOP; 
  The new escalation process has been applied successfully; 
  The JOP has been agreed and implemented by all stakeholders; 
  A Briefing and a Memorandum have been disseminated to staff which specify the process staff 
should  follow  when  there  is  a  warning  marker  on  a  property,  including  the  various  factors  that 
need  to  be  taken  into  account  in  their  risk  assessment  and  the  fact  that  the  service  user's 
property should be attended by the crew in order to carry out the dynamic risk assessment; 
  Training  is  being  rolled  out  to  Emergency  Operations  Centre  staff  in  relation  to  the  Police  risk 

assessment THRIVE; 

  Operational  staff  have  received  dynamic  risk  assessment  training  as  part  of  their  annual 

statutory and mandatory training; 

  Operational  staff  have  received  conflict  resolution  training  and  breakaway  training  as  part  of 

statutory and mandatory training; 

  Dashboard stickers have been developed to provide more information about police assistance; 
  Alan  Gallagher  has  met  with  the  various  managers  in  order  to  ensure  the  information  is  being 

disseminated; 

  Our staff's knowledge and awareness of the JOP is to be audited; 
  The Trust continues to collaborate with our emergency service colleagues and other partners. 

I can also confirm that in order to improve nationwide learning, the Trust have disseminated both the 
Regulation 28 Report and our response to other Ambulance Trust colleagues across the country.  The 
Care Quality Commission is also aware of the Regulation 28 Report and shall receive a copy of this 
letter of response. 

I  hope  that  the  steps  that  have  been  taken  address  the  matters  of  concern  which  you  have 
highlighted.  If the Trust can be of any further assistance please do not hesitate to contact myself or 
Alan Gallagher, Head of Risk at the Trust. 

Yours sincerely, 

Yvonne Ormston  
Chief Executive 

Enclosures 

Joint Operating Procedure (JOP) version 14 
Staff briefing, joint demand reduction programme 
Memorandum, risk markers/flags and dynamic risk assessments 
Resource Escalation Action Plan (REAP 

6