Reginald Key

Cannock Chase Clinical Commissioning Group
South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group

Stafford and Surrounds Clinical Commissioning Group
Cannock Chase CCG and Stafford and Surrounds CCG

' First Floor
Your Ref: MJJ/JS/897 13/2016 Staffordshire Place 2

Stafford
Our reference: MW/TLR/33881 San zie

Tel: 01785 356944
29 March 2018
South East Staffordshire & Seisdon Peninsula CCG

mi
Ms M Jones 2" Floor, Marmion House

HM Assistant Coroner eileen
Coroner's Chambers 879 7BZ
547 Hartshill Road Tel: 01827 306148
Stoke-on-Trent

ST4 6HF

Dear Ms Jones

The Late Reginald George Key

Thank you for your letter dated 30 January 2018 informing us of your concerns regarding the
transport home of the late Reginald George Key. Firstly | was saddened to hear of Mr Key's passing
and would like to thank the Coroner for informing us of their recommendations from the inquest which
was concluded on the 24 January 2018. In accordance with your request under paragraph 7,
Schedule 3 of the Coroners and Justice Act (2009) and regulations 28 & 29 of the Coroner's
Investigation Regulations (2013) | wii! outline the investigation undertaken by my team under my
direction as the Accountable Officer for the Staffordshire Clinical Commissioning Groups. | assure
you we have taken your report seriously and have dealt with the Provider of the service directly in all
aspects of our investigation to enable us to respond in line with the Regulations.

The area covered in my response pertains to Section 5 of your Regulation 28 Report- Preventing
Future Deaths dated 24 January 2018 and addresses the first two points you raised under your
concerns. These were as follows:

« The deceased had undergone surgery and was apparently discharged from the Royal Stoke
University Hospital at 6pm on 1 December 2016. He was collected by patient transport. Clinicians
tell me he was well on discharge. He was apparently delivered home at 10pm some four hours
later when he was described as being very unwell with paramedics commenting that he should
not have been discharged and that they had to carry him into the house. Family noted there were
other patients in the transport vehicle awaiting return home.

¢ Family and clinicians raised concerns about the length of time it had apparently taken to deliver
him home and whether or not his deteriorating condition was or could have been spotted and
whether there was an option for paramedics to return him to the hospital. He was returned to
hospital very unwell on the 04 December 2016.

Investigation Summary
Under the leadership of my Director of Nursing and Quality we have asked the

PTS Provider to conduct a full investigation of this case. As part of their investigation they have
reported to us they have conducted interviews with all staff concerned, however one half of the PTS
crew no longer works for the provider so can’t be questioned regarding whether there were any
concerns about Mr Key's health. The provider has spoken to the other half of this crew but they were
unable to re-call this transfer. There are no incidents !ogged for this journey. Without recall or
documentary evidence reporting any concerns we cannot confirm or clarify Mr Key's condition when
he arrived home.

We can confirm that Mr Key was transferred home by our commissioned Patient Transport Service
(PTS) on 1 December 2016. Their records have recorded his journey as ‘ready for discharge’ at

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Cannock Chase Clinical Commissioning Group
South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group

Stafford and Surrounds Clinical Commissioning Group

17:16 and show that he had been collected by the crew at 17:50. The PTS crew had left the hospital
at 18:09 and Mr Key arrived back to his home address in Hednesford at 19:15. We have confirmed
that the crew consisted of two patient transport assistants and that these were not paramedics. The
PTS service have no record of any concerns being raised by their crew under their deteriorating
patient policy and no indication that the journey deviated from the plan as indicated by their transport
monitoring system.

We have confirmed that the level of skill and knowledge of the PTS crew is of a first aid standard and
they were not qualified to administer assistance above this level of training. We have also confirmed
that the service has a deteriorating patient policy which is applicable for both during the journey and
at the point of discharge from their care. This policy instructs staff, in the event of deterioration or
concern, to seek assistance from the ambulance service by dialling 999, to administer first aid as
necessary and to inform their control room of any incidents and actions undertaken when enacting
the policy.

Investigation Findings

The PTS provider has interrogated their reporting system and clarified our challenges around the
timings of transport and Mr Key's condition. They have re-confirmed the times and have reviewed
their GPS vehicle tracker to confirm their recorded timings are accurate. They have confirmed their
records indicate that when they arrived at Mr Key's house they had one individual on board who was
awaiting onward transport. There are no reports of Mr Key being unwell on pick up or when they
arrived at his abode. The vehicle was booked as a patient transfer in a chair requiring two PTS crew
to take him safely home. There is no indication in the records of any deviation from the planned
transfer route and records confirm he was transferred to his home in a chair.

We have discussed the level of skill and escalation procedure with the PTS provider. They have
reported all staff are aware of the deteriorating patient policy and they expect staff to enact this when
they have any patient concerns. Staff are instructed at times of a medical emergency and/or
concerns around the patients’ health, that they are to stop the vehicle and inform the ambulance
service of the nature of the emergency and await the service to respond. It is important to highlight
that they are not allowed to transport a patient to hospital and are required to seek professional help
via the 999 service.

Should transfer to hospital be required this would be conducted by the 999 service. Their level of
training is to administer first aid where needed and to commence interventions such as cardio-
pulmonary resuscitation in emergencies should this be required. They are not allowed to diagnose or
assess the patients’ health above their first aid skill level. If they have concerns under this policy they
are to record this with their control room and log their actions undertaken. However, without recall or
documentary reporting they were unable to establish what was discussed with Mr Key’s family. We
are assured that our commissioned PTS provider discourages their non-paramedic staff from
assessing a patient's condition other than as would be expected from their first aid training and to
promptly discuss their concerns with the 999 service to ensure no delays in receipt of assistance.

Assurances Undertaken to Prevent Future Deaths

To address the Coroner’s concerns we have instructed the provider to act upon the findings and
include in their action plan the following:

¢ To review their deteriorating patient policy.

¢ To expect commissioners to monitor any reported elongated journey times at both the contract
and quality meetings.

¢ To undertake a deteriorating patient policy awareness campaign with staff utilising a variety of
mechanisms including one to one awareness, staff group awareness and a promotional
campaign.

¢ To reinforce their first aid training to identify a deteriorating patient and appropriate escalation.

@ We are honest, accessible @ Quality is our day job @ We innovate and deliver © Care and respect for all
and we listen

Cannock Chase Clinical Commissioning Group
South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group
Stafford and Surrounds Clinical Commissioning Group

e¢ To review their incident recording mechanism from crew to control room and to establish a
measuring process to assure that this remains consistent.

e To establish a procedure to cross check journey times against their vehicle tracking systems to
assure that patients are not being transferred or delayed for protracted periods.

¢ To identify specific actions to identify good practice in communicating with patients and relatives.

We have instructed the provider to produce an action plan to address these matters. This plan will
be reviewed in detail at the next provider contract and quality meeting in April 2018 by my
commissioning and quality teams and will be monitored at this meeting until all actions are concluded
and agreed between the provider organisation and the CCGs.

We expect these actions to be expedited and we have requested measurable outcomes to be
reported. From this action plan we expect the provider to have embedded the identified learning from
the Coroner’s concerns. We hope these actions will enhance the patient experience of our
commissioned PTS service and will reinforce the safety of our patients being transferred home.

| would like to thank the Assistant Coroner for bringing their concerns to my attention. | hope that we
have demonstrated our commitment to preventing future deaths in this case. Should you require any
further information in relation to this response | would urge them to contact me without hesitation.

Yours sincerely .

Accountable Officer

@ We are honest, accessible  @ Quality is ourdayjob | We innovate and deliver @ Care and respect for all
and we listen