Diana Gudgeon

BHT

111 (East Midlands)
Pe CIC

Johnson Building
Locomotive Way

Mr Hassan Shah, Pride Park
; Derby
Assistant Coroner DE24 8PU

Coroner area of Northampton Tel: 0300 1000 404

Coroners@northamptonshire.gov.uk Fax: 0300 1000 405

Dear Mr Shah

Re: REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS /
DIANA GUDGEON

| write in response to your query raised regarding the 111 service as follows:

Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis. The

patient had collapsed, passed out, been confused and had been vomiting. These are signs
of central nervous system/neurological problems but were not regarded as urgent. Despite
EMAS being told that the patient may have a urinary tract infection, no escalation occurred.

Explanation as follows:

The NHS 111 service and some 999 services, use NHS Pathways software which consists
of algorithms developed nationally by the Royal Colleges of GP’s, Paediatricians,
Emergency Medicine, and Psychiatry etc. All sites using the software contribute to feedback
on these algorithms and versions are updated twice yearly. We are using NHS Pathways
version 16.0 at the present time which is the most up to date version.

The call has been reviewed against NHS Pathways version 14, which was in use at the time
of the call. The key question relates to whether the patient was severely ill. The response
from the son was unclear in answering this question. The Health Advisor (who is trained in
the use of NHS Pathways, but who is not a clinician) could have probed this question more
appropriately by utilising the supporting clarification information within NHS Pathways in
order to get a clearer answer to this question. However, in order for this question to have
been answered positively there is a second part to the question which asks whether the
patient has new marks like bruising or bleeding under the skin. Both severely ill and the new
marks have to be present in order for this question to be answered positively.

Answering this question positively is the only way that the disposition of a Category 2
ambulance could have been reached. As the severely ill stem was answered negatively the
stem asking about new marks was not asked, but no rash was mentioned on the call. We
have reviewed the case and used the other presented symptoms such as a fall, vomiting and
behaviour change and the highest disposition we could have reached is a Category 3

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ambulance.

DHU 111 (East Midlands CIC is a Limited Liability Company. Registered in England Number: 10259076
Registered Office: Johnson Building, Locomotive Way, Pride Park, Derby, DE24 8PU

Eee mene

A very high blood sugar test over 27.9mmol as opposed to the reported 16 mmol would only
have triggered a Category 2 ambulance if the severely ill and new marks question had also
been answered positively.

Over the last year we have shared our concerns regarding NHS Pathways ability to pick up
possible sepsis effectively and have fed our concerns back to them. This has resulted in
changes to NHS Pathways in both versions 15 and 16. We have taken this call through NHS
Pathways version 16 to try to identify the likely outcome had this version been in place at the
time of the call. In version 16 the severely ill and new marks question has changed
significantly. Firstly the 2 parts have now been split into separate questions. Due to concerns
that the severely ill part of the question was too subjective this has been altered to “so ill they
have stopped doing all normal activities”. The new marks part of the question is separate
and triggered by answering the so ill they have stopped doing all normal activities question
positively. The wording of the new marks part is unchanged.

Having followed this call through version 16 of NHS Pathways a Category 2 ambulance
would only have been triggered if both the so ill they have stopped doing normal activities
and the new marks questions had been answered positively.

In summary both the version of NHS Pathways in use at the time and the latest version
would have required new marks to have been present in addition to the patient to have been
severely ill in order for a Category 2 ambulance to have been triggered. We attach copies of
the questions relating to severely ill and marks in both NHS Pathways version 14 and 16 for
your information. However the wording of the questions in version 16 has improved and
supports Health Advisors to answer the questions in a more straightforward manner. As the
question was not asked we are unaware whether a rash was present.

Category 3 ambulance dispositions have a target response time of 90% of calls being
reached with 120 minutes and a new target has been added of a mean response within 1
hour. We understand that EMAS have a policy of contacting patients at the point they are
likely to breach the 120 minute target to ensure there has been no change in the patient’s
condition. We note that a clinician from EMAS did call around the time of the anticipated
breach to assess the patient. We note that following this call no escalation occurred.
Category 2 ambulance dispositions have a target response time of 18 minutes with 90% of
calls to be reached within 40 minutes

As part of the NHS pathways training, new Advisors cover sepsis as part of the Distance
Learning Pack (DLP), see attached. The information within this pack is formally assessed by
means of an exam paper which advisors have to achieve a pass rate of 70% and above to
continue with the course. The Advisors cover scenarios in training which aid them with
exploring the Pathways system, which include symptoms of sepsis. In addition to this, all
Advisors attend Spotting the Sick Child training which covers NICE Guidance of feverish
illness in under 5’s and the sepsis risk stratification tool (see attached)

The Clinicians all receive the Sepsis Risk stratification tools as part of their clinical training.
The Clinicians have all been notified of a free online course on Sepsis in Primary Care on

Ko

the following website https://Awww.e-lfh.org.uk/

DHU 111 (East Midlands CIC is a Limited Liability Company. Registered in England Number: 10259076
Registered Office: Johnson Building, Locomotive Way, Pride Park, Derby, DE24 8PU

THE SOCIAL ENTERPRISE MARK
“roanine eno DENBIE An DL AMET

| do hope that the above explanation has addressed your concerns. If however, there are
any matters which are still outstanding or points which are unclear please do not hesitate to
contact me via the Clinical Governance Department, at the above address or via the clinical

governance e mail: DHUL.ClinicalGovernance@nhs.net or telephone 0300 1000 407

Yours sincerely Countersigned by

Cf a
Dr lan Matthews Jenny Doxey

Medical Director Clinical Director

eos

DHU 111 (East Midlands CIC is a Limited Liability Company. Registered in England Number: 10259076
Registered Office: Johnson Building, Locomotive Way, Pride Park, Derby, DE24 8PU

THE SOCIAL ENTERPRISE MARK

TRANINR EAB BENPIE ANN pI ANET

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East Midlands 
Ambulance Service 
NHS Trust 

Trust Headquarters 
1 Horizon Place 
Mellors Way 
Nottingham Business Park 
Nottingham 
NG8 6PY 
PALS telephone: 0333 012 4216 
Head office telephone: 0115 884 5000 
Fax: 0115 884 5001 
Website: www.emas.nhs.uk 

7 March 2019 

Confidential 
Mr Hassan Shah 
Assistant Coroner 
Constabulary Block 
Angel Square 
Northampton 
NNl lED 

Dear Mr Shah 

Re: Report to Prevent Future Deaths: Ms Diana Gudgeon 

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 9 January 2019, bringing 
to my attention HM Coroner's concerns arising from the inquest into the death of Ms Diana 
Gudgeon. 

I would like to assure you that matters related to patient safety are taken extremely seriously by 
the Trust.  In particular, matters arising from Coroners' Inquests from which lessons can be learnt, 
including Prevention of Future Death Reports, are discussed within the Incident Review Group and 
Lessons Learned Group. 

Coroner's Concerns 

1.  Triaging by '111' and EMAS call handling systems, including in relation to sepsis. In the 
present case, Mrs Gudgeon had collapsed, passed out, been confused and had been 
vomiting. These are signs of central nervous system/neurological problems but were not 
regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract 
infection, no escalation occurred. 

Each individual call received by the Trust is either triaged via the Advanced Medical Priority 
Dispatch System (AMPDS), using the information provided to us either by the caller or is 
received via the electronic gateway from NHS Pathways - the 111 system.  The AMPDS is an 
internationally recognised triage system that uses a data set to determine the response level 
required, based on the information provided during the call. 

The call is categorised at source, according to the information provided by the individual 
caller or the system.  At this time there was no information provided by the caller that 
warranted an escalation of the call. 

Respond I  Develop I  Collaborate 

 W hen we re-contacted the patient at a  later time, no additional info rmation was pro vided 
and the call remained as the same category. 

If additional info rmation had been provided to the call taker that triggered an escalation via 

AMPDS to a higher category, this would have escalated the call to a higher category. 

2.  It was suggested in evidence that if the same facts are inputted into the '999' AMPDS 
triaging system they are likely to allocate a higher priority to the call than the '111' 
Pathway triaging system would. 

Both AMPDS and NHS Pathways are advanced clinical triage systems designed to enable the 
call taker to process a 999 call based on information received from the caller and to arrive at 
a response priority.  The two triage systems operate within different algorithms and with a 
different series of questions to ask the caller when prioritising the call. 

As each system has differing algorithms and different question sets, and each 999 call is 
managed as an individual call, there will be occasions where different priorities may be 
attributed to the same set of circumstances within each triage system. 

As an example, AMPDS ambulance trusts more often have a higher proportion of Category 2 
999 calls than Trusts that use NHS Pathways. 

3.  The shortage of double crewed ambulances and fast response vehicles in the 

Northampton Division. 

A jointly commissioned, independent "demand and capacity review" identified a gap 
between the resources presently available, and what was needed to deliver national 
performance standards for ambulance services. 

In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning 
Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG 
which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the 
terms for up to £9m extra funding for clinical staff, ambulances and other resources being 
provided in the first year. This could potentially rise to approximately £19m next year, 
dependent on performance targets being met and other financial agreements made as part 
of the contract terms. 

The funding will directly address the gap identified in the demand and capacity review, and 
is expected to result in a stepped improvement in the Trust' s ambulance response times and 
consistency of response across all areas of the East Midlands region. The additional money 
will be invested in the right level of resources to enable the Trust to respond more quickly 
and consistently to 999 calls and urgent GP requests and to achieve national standards at a 
county level, which came into force for all ambulance trusts in autumn 2017. 

Since the additional funding was announced and as at the end of February 2019, the 
Northamptonshire Division have recruited an extra 39 frontline staff and further staff are in 

Respond I  Develop I  Collaborate 

 the process of being recruited.  20 staff are now recruited, trained and operational.  The 

remainder in training will commence training in the next quarter.  To support the additional 

resources, we are also recruiting private providers with qualified staff. 

4.  The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, 

inter alia, the fact that:- 

a)  CMP status 1- 3 does not trigger the deployment of additional vehicular 

resources. 

b)  CMP 4 is only triggered when 200 calls are holding (this was previously 150) - this 

is a high threshold. 

c)  A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding 
(CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander. 

We do look to move resources from one Division to another and therefore we have to balance 
against how many jobs are holding in each Division.  On this occasion, it was unfortunately not 
possible to move any resources. 

The Trust's Capacity Management and Escalation Plan has been through a rigorous governance 
process and the triggers are regarded as a safe process for managing our demand.  The Plan is 
reviewed on an annual basis. 

Given the complexity of the CMP I would like to suggest that a further, detailed explanation be 
presented to HM Coroner or representative. Alternatively we could arrange for a visit to our 
Emergency Operations Centre to see the CMP in place; we could also take the opportunity to 
illustrate the AMPDS triage system at this time.  If you feel that this would be beneficial, Mrs 
Natalie Harrison, Coroner Services Manager, will be pleased to make the necessary arrangements. 

I  hope that the measures set out in this letter provide you with the appropriate level of assurance in 
relation to our commitment to continuous improvement of services. 

Please do not hesitate to contact me should you require any additional information, or any 
clarification, in connection with the above. 

Yours sincerely 

Richard Henderson 
Chief Executive 

Respond I  Develop I  Collaborate