Prevention of Future Deaths reports · 2018

Raymond Davidson

Regulation 28 report to prevent future deaths, reference 2018-0059, written 27 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Feb 2018
Reference2018-0059
DeceasedRaymond Davidson
CoronerDerek Winter
Coroner areaSunderland
CategoryCommunity health care and emergency services related deaths
Organisation namedNorth East Ambulance Service NHS Foundation Trust · Yvonne Ormston the North East Trust NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Private and Confidential 

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

23rd April 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/HMC1519 

Inquest into the death of Raymond Henry Davidson (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 27 February 2018 as issued following the Inquest into 
the tragic death of Mr Davidson.   

In your report, you highlighted the following concerns: 

“This is the third such report about the same issue that I have written in recent months as I 
consider that there is a risk of future deaths. An urgent review of resources and their application 
is needed. 
Finally from the evidence, there was frequent telephone contact made, but this was not with 
the patient directly, which may have impacted on the less than robust initial clinical review of 
Raymond's condition”. 

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

Review of Resources  

Over the past three years we have had a number of external reviews, each looking in detail at 
different aspects of the service, which all identify that NEAS is under-resourced. These findings 
have  come  from  the  CQC  inspection  November  2016;  the  National  Audit  Office  report  in 
January 2017; and the most recent Carter Review.  

The Trust Board has also expressed serious concerns about patients’ safety due to the lack of 
resources to send to patients waiting on the stack for an ambulance to arrive, and this has also 
been mirrored in correspondence from Senior Coroners. 

The National Audit Office report (January 2017) indicates that the Trust has the lowest levels 
of  funding  in  England.  The  scale  of  variation  -  almost  £10  per  head  of  population  across 
ambulance  trusts  in  England  -  indicates  the  challenge  we  face  if  we  are  to  meet  our 
performance standards. If the Trust had the same level of income as the England average, 

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). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 based on achievement of the historic performance standards the Trust would benefit from an 
additional £15.6 million.  

The  Trust  in  collaboration  with  our  lead  commissioner,  Durham  Dales  Easington  and 
Sedgefield  Clinical  Commissioning  Group  (CCG),  jointly  procured  Operational  Research  in 
Health Limited (ORH) to undertake a Demand and Capacity Review of the Trust. This included 
drawing  a  line under our  historic funding  issues. The  report by  ORH,  who  are  specialists  in 
emergency  services  modelling,  sets  out  clear  recommendations  for  the  Trust  and  the 
commissioners.  

The  overall  aim  of  the  review  was  to  determine  the  underlying  capacity  required  to  deliver 
ambulance  response  time  performance  across  the  North  East  Ambulance  operational  area, 
designed  to  meet  the  new  national  ambulance  targets  and  the  Trust’s  own  performance 
objective in the period to 2021/2022. 

The scope of the review focused upon the following areas;  

  Demand predictions to 2021; 
  Model performance to 2021 with current resourcing; 
 
  Model performance impact of each potential efficiency; 
  Model resource needs to bridge any performance shortfall. 

Identify potential efficiencies; 

I  am  cognisant  that  I  have  previously  detailed  the  work  we  are  undertaking  to  address  our 
recruitment and performance challenges. I therefore intend on omitting these details from my 
response and shall focus on the findings detailed within the report. 

Report Findings and Trust Actions 

We believe the implementation of the ORH recommendations will enable a safe and responsive 
service to be delivered to our patients; including 100 additional paramedics required. 

Delivery  of  the  new  ambulance  response  standards  is  dependent  on  receipt  of  a  recurrent 
annual cost of investment of £10.4 million, identified from the ORH report, of which: 

  £3.9 million is funded recurrently from additional investment made by commissioners in 

2017-18 in recognition of our CQC rating and NAO report; 

  £2.6 million is funded recurrently from a 2.5% uplift in 2018-19 contract variation agreed 

with commissioners; 

  We  have  jointly  agreed  with  commissioners  that  the  shortfall  of  £3.9  million  is  to  be 
discussed  to  allow  the  CCGs  to  better  understand  the  details  of  the  ORH 
recommendations before making any further future commitment; 

−  We are aiming to develop and approve an action plan by the end of May 2018 
that will include timescales to address the shortfall in funding and deliver the ARP 
standards; 

−  Within this agreement, an assumption is made in the ORH report that abstraction 
rates of frontline staff are reduced from 34.4%. A target abstraction level of 25%, 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 agreed by the Trust, would require a relief rate of 33.3%. Assuming this 33.3% 
relief  rate,  1,219  whole  time  equivalents  are  required  to  put  out  the  planned 
rosters without dropping shifts due to absences. We have committed to achieve 
this efficiency, which will realise £7.4 million efficiencies over the next five years, 
as  an  equal  share  of  the  funding  commitments  required  to  achieve  the  ARP 
standards. 

Separately, we have raised a significant patient safety concern with commissioners over their 
decision  to  withdraw  £1.3  million  from  our  999  emergency  operations  centre  by  September 
2018. This removes a significant number of clinical support advisers to our 999 call takers and 
dispatchers.  Commissioners  have  communicated  that  they  will  address  our  concerns  in 
September 2018 after the completion of the NHS111 procurement process in the North East 
of England. 

In  detail,  the  ORH  report  highlighted  a  number  of  areas  of  focus,  which  is  pertinent  to  this 
particular case: 

1.  Benchmarking  indicated  that  a  significant  improvement  in  control  activation 
times is feasible, aiming to reduce average C1 activation times from 2 minutes to 
60 seconds by 2021/22.  

We are working towards an improvement in control activation times, compared to other Trusts. 
These have deteriorated within NEAS over the last two years. We aim to reduce C1 activation 
times from 2 minutes to 60 seconds by 2021/22. 

The  delay  in  allocation  of  an  ambulance  response  to  this  call  was  unfortunately  due  to  the 
demand  placed  upon  the  service  at  the  time.  The  dispatch  team  do  endeavour  to  move 
available resource into an area depleted of available cover to ensure a suitable response can 
be  activated.  However  in  this  instance  all  resources  were  responding  and  dealing  with 
emergency calls in the surrounding areas. 

We are working with ORH to look to improve our crew shift start and finish times.  This will also 
assist  with  better  overall  availability  of  crews  throughout  the  shift.  We  are  also  looking  to 
improve  the  productivity  of  the  dispatch  teams  by  reducing  the  number  of  ambulances 
managed by each dispatcher. 

The Dispatch managers monitor on a monthly basis through audit, the allocation times of the 
dispatch  team.    The  time  frames  are  monitored  in  line  with  national  guidance  to  ensure 
compliance.  Individual training and actions plans can and are issued with any dispatcher who 
needs further support in ensuring calls are allocated within the given dispatch standard times  

2.  Some  reduction  in  conveyance  rates  is  also  feasible,  with  a  corresponding 

increase in time at scene, particularly in Central and North divisions. 

We are undertaking a targeted piece of work to reduce conveyance rates. We aim to reduce 
C2 conveyance rates in Central (81%) division, which includes Sunderland, and North (79%) 
division to comparable levels with our South division (74%) by 2021/2022 

We  are  working  with  Northumberland  CCG  to  put  in  place  a  rapid  response  team  who  will 
provide  a  multidisciplinary  team  to  respond  to  a  wide  range  of  lower  acuity  cases  in  the 
community  to  provide  paramedics  with  an  alternative  option  to  ED.  We  have  provided  50 

3 

 
 
 
 
 
 
 
 
 
 
 
 additional E-Care course places to provide staff with the necessary skills to be able to safely 
and confidently leave patients at home who do not need to be transferred to hospital. We are 
seeking funding to be able to roll out paramedic pathfinder across the region to support the 
work that is currently being done in Sunderland to provide a range of alternative pathways for 
staff to refer patients to. This is dependent upon CCG funding. 

3.  A  reduction  in  time  at  hospital  should  be  targeted,  particularly  in  Central  and 
North divisions, aiming to reduce to a 30-minute mean by 2018/19 in each division. 

We  are  actively  working  to  reduce  time  at  hospital  and  we  acknowledge  there  have  been 
significant increases in the last two years. We aim to reduce to a 30-minute mean by 2018/2019 
in each division. An example of our work is the introduction of a new handover procedure and 
monitoring system. Upon introduction on 29 November 2017 we have witnessed a decrease in 
handover to clear times of approximately 5 minutes. 

We are working with our partners across the region in a Task and Finish Group to focus on 
ambulance  handovers.  We  hold  a  weekly  conference  call  with  all  of  the  acute  trusts,  NHS 
England,  NHS  Improvement  and  the  North  East  Urgent  and  Emergency  Care  Network  to 
address  issues  and  formulate  strategies  to  improve  handover.  We  have  developed  a  joint 
standard operating procedure for handover across the region which has been in place since 
November.  We  are  working  together  to  ensure  that  there  is  a  culture  of  accountability  for 
handover  embedded  in  both  the  acute  and  ambulance  Trusts  at  grass  roots  level.  Hospital 
Handover is part of every individual’s objective and discussed during performance reviews and 
ride-outs.  We  are  basing  an  Operational  manager  permanently  within  two  acute  trusts  to 
monitor and manage the handover process and build relationships within the hospital to ensure 
that issues are escalated early so we can take proactive action before we start to experience 
handover delays  

4.  In  addition  to  these  efficiencies,  the  ORH  modelling  went  on  to  look  at 
opportunities for rostering crews and vehicles more effectively, and ensuring that 
the resource mix is appropriate for the new ARP operational regime. 

In the re-rostered position, there is a shift from Rapid Response Vehicles (RRVs) and Urgent 
Care vehicles to Double Crewed Ambulances (DCAs), and resourcing has been reduced at 
night with a corresponding increase in the day. All six ARP measures are comfortably met in 
this scenario with the additional funding. 

However, our ability to produce efficiencies requires more front line capacity to deliver service 
improvement. This is dependent on funding to invest in a higher skill mix of qualified staff to 
improve see and treat outcomes; and ambulance activation time improvements being achieved 
by having more vehicles available. Like other ambulance trusts, we are under huge financial 
strain and are adapting to the new targets in the midst of a major workforce shortage and a 
need to modernise our fleet. Our cost improvement programme currently stands at around £8 
million. This represents more than 6% of our annual turnover. 

The Trust has started to share the content of the ORH report with stakeholders via a number 
of  engagement  events.  We  have  established  an  implementation  group  who  will  develop, 
implement and oversee a detailed implementation plan. This will include current rosters versus 
new,  staffing  implications,  vehicles  and  estates.  The  Trust  and  partners  are  reviewing 
contractual implications alongside the approval processes. 

4 

 
 
 
 
 
 
 
 
 
 Telephone Contact with Patient/Caller 

I can confirm that the updated ‘Urgent Ringback Procedure’ was approved and implemented 
in  February  2018.  The  updated  procedure  is  available  and  communicated  onto  all  Call 
Handlers, Clinicians and Team Leaders within the Trusts Emergency Operations Centre. The 
new procedure puts the emphasis on direct conversation with the patient wherever possible. 
In relation to the 111 Clinician, the individual was provided one-to-one feedback on this case 
and undertook a coaching session. 

Since  the  end of  2016,  the number  of  clinicians  available  within  the  Emergency  Operations 
Centre to support both call handlers and patients who are waiting for a resource has increased. 
In addition, they are now supported and led by a larger team of Clinical Section Managers and 
are provided with appropriate coaching and feedback routinely. 

Clinicians  now  adopt a  more  structured  approach to  support  waiting  patients  to ensure that 
consistent  contact  is maintained. And a  lead  clinician  or  Clinical Section  Manager oversees 
outstanding workload and ensures relevant support is provided to clinicians managing each 
area.  Clinician’s  calls  are  also  audited  by  a  Clinical  Auditor,  auditing  4  calls  per  month. 
Feedback is then provided to the individual Clinicians on positive and developmental areas. 

The Trust has also implemented a robust REAP / Escalation Policy which details very clearly 
the actions to be taken within the Emergency Operations Centre and by Operational staff in 
line with demand.     

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 

5
Also filed under 2018-0059: Raymond-Davidson-2018-0059.pdf
Derek Winter DL
Senior Coroner for the City of Sunderland

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: -
Ms Yvonne Ormston

Chief Executive
North East Ambulance Service NHS Foundation Trust (NEAS)

CORONER

I am Derek Winter DL, Senior Coroner for the City of Sunderland

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation. gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 10" June 2017 Mr Raymond Henry Davidson (Raymond), aged 69 years, died at his
home address. The Inquest, as part of my Investigation, concluded on 27" February 2018,
when I recorded a conclusion of Natural Causes Contributed by Neglect.
The Cause of Death following Post-Mortem Examination was: -

Ia Large Bowel Voluvlus

CIRCUMSTANCES OF THE DEATH

On the 9" June 2017 at 15:19, NEAS received a call into 111 from a gentleman to
highlight concerns for his brother. At 15:39, the 111 clinician triaged to a GP contact
within 2 hours.

On reviewing this call, it was found that this decision was not as robust as it ought to have
been.

At 17:45 an Urgent booking was received by ambulance control to arrange an Urgent
ambulance within 2 hours to transport Raymond into Queen Elizabeth Hospital. No
ambulance attended.

At 20:11 the first welfare call was completed with no worsening symptoms described.
This was followed with further welfare calls at 21:54, 23:04 and 00:05 with no worsening
symptoms described.

At 01:05 the Call handler called a clinician to highlight the fifth welfare call was about to
be carried out, and advice to upgrade the call was given.

At 01:07 the case was therefore upgraded and prioritised as a G2 emergency response
(within 30 minutes). No Ambulance attended.

Raymond’s brother rang 999 at 02:02 as Raymond had stopped breathing.

Civic Centre, Burdon Road,Sunderland, SR2 7DN
Tel 0191 5617843 | Fax 0191 5537803
www.sunderlandcoroner.co.uk

The case was upgraded to a R1 emergency response for within 8 minutes and CPR
instructions given.

The Rapid Response arrived on scene at 02:10, but Raymond had sadly passed away
before the arrival of the crew.

CORONER’S CONCERNS

I heard evidence that: -

e the recruitment/retention of staff had improved; and

¢ welfare calls triggered earlier clinician involvement than previously; and

¢ although there were several other initiatives under way, operational shortages were
ongoing.

Raymond’s death highlighted resource issues. There was only so much NEAS could do

when they simply did not have enough ambulances to send. At times demand was greater

than the resources NEAS had available. The effect of urgent cases being interposed put

back those cases appearing to be less urgent. In this case: -

e 10 hours 51 minutes elapsed from the original 111 call;

e 8 hours and 29 minutes after the urgent categorisation; and

¢ 1 hour 3 minutes after the case was prioritised as a G2 response.

This is the third such report about the same issue that I have written in recent months as I

consider that there is a risk of future deaths. An urgent review of resources and their

application is needed.

Finally from the evidence, there was frequent telephone contact made, but this was not

with the patient directly, which may have impacted on the less than robust initial clinical

review of Raymond’s condition.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 27" April 2018. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

Ihave sent a copy of my report to the Chief Coroner and to the following: -
e Family
e Secretary of State for Health
e Head of Risk — Quality and Safety, North East Ambulance Service NHS
Foundation Trust and Trust’s Solicitors
e Care Quality Commission (CQC)
Iam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of

interest. You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response by the Chief Coroner.

Dated this 27" day of F ebruary 2018

Signature d AD

Senior Coroner for the City of Sunderland

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