Olive Nutt

London Ambulance Service [4'/s/3

NHS Trust
220 Waterloo Road
London
SE1 8SD

Tel: 0207 783 2001
Mr Russell Caller Fax: 0207 783 2009

HM Assistant Coroner for Inner West London
Westminster Coroner’s Court

65 Horseferry Road

London

SW1P 2ED

www.londonambulance.nhs.uk

5* September 2018

Dear Mr Caller
Regulation 28; Prevention of Future Deaths Report arising from the inquest into the death of Olive Nutt

Thank you for your Regulation 28 Report received on 24" July 2018 bringing to my attention matters of
concern.

| would like begin by offering my sincere condolences to Mrs Nutt’s family and | hope that this reply will be
helpful in confirming the actions taken to demonstrate how the matters of concern have been addressed and
the ongoing work to make improvements within the London Ambulance Service NHS Trust (LAS).

| will address your concerns as follows:

The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were
phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which

caused significant delay in a timely attendance being made on the deceased.

LAS acknowledge ani logise for the regrettable delay in Mrs Nutt receiving an LAS resource. As set out in
the evidence ‘oe Quality Assurance Manager at the inquest on 26'" June 2018, the Emergency
Medical Dispatcher (EMD) for CAD 3620 did not apply the Medical Priority Dispatch System (MPDS) protocol
correctly. MPDS is an internationally recognised and utilised system of 999 call triage and dispatch of
ambulance resources.

The error on the part of the EMD resulted in a potential under triage of the call, although as HB set out in
her evidence, we are unable to say whether the call would have received a higher priority as we will never
know what the answer would have been if an additional question about whether the patient was alert, as
opposed to being confused or disorientated, had been asked.

The EMD handling call CAD 3620 on 29" January 2018 has recognised their error and received prompt feedback
on the incorrect application of the MPDS system and LAS protocols for call handling and triage. The EMD has
reflected on this and learning points have been taken to reduce the risk of this situation, where an opportunity
to record information given by a caller is missed, and to ensure best practice is achieved in the use and
application of the MPDS protocol.

In addition, our most recent Core Skills Refresher course for Control Services staff which began on 2™ August
2018 and will run until the end of March 2019, includes refresher training on call handling and the application
of the MPDS protocol. This refresher course will also specifically include an anonymised case study of the issues
highlighted in the management of CAD 3620 as a ‘learning from experience’ example. All EMD staff are
required to attend the CSR training and this case study is designed to provide EMDs with an example of best
practice in applying the appropriate protocols when faced with this type of situation, to improve service
delivery to patients.

The LAS breached its own pre-set time guidelines in failing to return a call to the deceased’s home to take
further details of her medical conditions.

Resourcing

During the afternoon of 29" January 2018 demand in the service was above that predicted and staffing levels
both operationally and in the Clinical Hub were below the below the planned level.

For a day shift the minimum staffing level on the Clinical Hub is eleven members of staff, the level set by a
matrix devised in 2013. Work is currently being undertaken to reassess the minimum staff levels in light of the
changes within the new national response standard (ARP) and given that demand on the service has continued

to increase since 2013.

| set out in her evidence, by 17.00 hours around 150 calls were being held across London and this
had reached more than 200 by 19.00 hours. Staffing for the Clinical Hub was challenging due to the volume of
calls with one staff member above minimum levels to 19.00 hours and then one below minimum levels for the
next hour. The Clinical Hub was holding 20 — 25 calls in the dispatch ring back group with only 3 — 4 clinicians
available to ring back Category 4 calls which were on hold within the Clinical Hub dispatch group. A Category 4
call should be called back for a telephone assessment within 90 minutes and regrettably this did not happen on

this occasion.

Due to the fact that demand for operational staff was high and Operational staffing was also a challenge, it was
unfortunately not possible to call clinical staff in from the front line to work on the Clinical Hub to increase
staffing numbers on this day, which is an option if demand and staffing allow.

Resourcing is an ongoing challenge for LAS and we continue to work to address this, including securing funding
for additional recruitment. | am very sorry that these difficulties resulted in a delay in ringing back Mrs Nutt to

undertake a telephone assessment in a timely way.

Clinical assessment

The Clinical Hub clinician called Mrs Nutt at 19,37 hours, 2 hours and 6 minutes after the initial call. The Clinical
Hub clinician who made the call back to Mrs Nutt had been due to finish her shift at 19.00 hours however due
to the large volume of calls being held she continued to work weil over the end of her shift on this day. Mrs
Nutt spoke to the Clinical Hub clinician but a full Manchester Triage System triage could not be completed due
the communication difficulties between Mrs Nutt and the Clinical Hub clinician. As such the Clinical Hub
clinician correctly upgraded the call to a Category 3 response at 19.46 hours and also safety netted her decision
by contacting Anchor care line to check Mrs Nutt’s history.

Of note, evidence of good practice was demonstrated by the clinician on the Clinical Hub on this occasion in
that she made a note on the log of the reason for the delay in ringing back Mrs Nutt. It is not mandatory to do
this but it is recognised that to record this information is very helpful and enables other staff members to see
where an issue has arisen and the cause of it.

Inclusion of this information is also recognised as helpful for data capture and identifying learning. This
example of best practice will now be included in the next Manchester Triage System update which is provided
regularly to Clinical Hub clinicians and it will also be included as a ‘learning from experience’ update which is
run regularly for Clinical Hub staff to identify areas of learning and promote best practice.

Expansion of the LAS Clinical Hub

LAS are always striving to improve our service to patients and a significant amount of work is currently
underway to expand our use and availability of the Clinical Hub. We currently have a Clinical Hub based at both
our Waterloo and Bow sites. A planned expansion of the Clinical Hub facility involves the introduction of three
additional Clinical Hubs in Kenton, Barking and Croydon which are planned to be in use by March 2019.

We are also planning to introduce a further Clinical Hub in New Maldon by the end of 2020. This will be a total
of six Clinical Hubs for LAS with a view to covering each of our operational sectors.

The premise of this expansion is to allow for greater and more flexible staffing on the Clinical Hub and to assist
with our winter resilience plan. LAS clinical staff have indicated it would be a more flexible option for them to
book on to shifts more locally to their station rather than having to travel to sites at Waterloo and Bow. This
will result in a larger pool of staff available to work on the Clinical Hub. The additional locations will also allow
for the shift patterns to be more flexible with the option for staff to booking on to shift on the Clinical Hub for
2- 3 hours or half a shift either before or after working the rest of their shift on front line duties.

All staff working on the Clinical Hub are fully trained in the Manchester Triage System and they must undertake
a minimum of one shift per month on the Clinical Hub to maintain their licence.

The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical
Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester
Triage System and with specific Clinical Hub training.

Improvements in accessing patient medical history

LAS have access to Summary Care Records, Co-Ordinate My Care and Adastra Electronic Patient Management
system for all patients across London. These systems enable clinicians in our Clinical Hub to check a patient’s
medical notes and history. In addition, we will shortly have the benefit of a new version of Adastra, which will
allow further access to records in CCGs which have signed up to this system. It will search five to six systems
including NHS111 records, GP notes, mental health care plans, special patient notes and child protection plans
and will continue to increase its range. This system will be of enormous benefit to LAS clinicians and will bring
about a greater consistency in decision making for patient care.

Ambulance Response Times

| understand you expressed an interest in the response times assigned to call priorities. A national review is
currently being undertaken, led by the Association of Ambulance Chief Executives (AACE) in the process of
ringing back patients and safe systems and LAS will respond to any actions and outcomes from this. LAS are
playing a significant role in this national review by submitting our data which is being used, in conjunction with
other ambulance services, to identify areas for improvement and learning and also to identify and promote

areas of good practice.

Yours sincerely

Saivett Emmerson

Chief Executive, London Ambulance Service NHS Trust