Paul Mclean

Ymddiriedolaeth GIG
G | G Gwasanaethau Ambiwlans Cymru

N H S Welsh Ambulance Services
NHS Trust

Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol
Regional Ambulance Headquarters and Clinica! Contact Centre
Ty Vantage Point / Vantage Point House, Ty Coch Way, Cwmbran NP44 7HF
Tel/Ffén 01633 626262 Fax/Ffacs 01633 626299

www.ambulance.wales.nhs.uk
CHAIR AND CHIEF EXECUTIVE'S OFFICE

Our Ref: JK/5662
19 December 2019

PRIVATE & CONFIDENTIAL
Mr Graeme Hughes

Acting Senior Coroner

South Wales Central

(sent by e-mail)

Dear Mr Hughes
Re: Inquest relating to Mr Paul Mclean

| write in response to the Regulation 28 report that you issued to this Trust, dated the
22 October 2019, following the sad death of the late Mr Paul Mclean who sadly died
on 9 October 2018.

In the Regulation 28 report you raised your concerns in relation to four matters

1. The adequacy/accuracy of the scripting of questions for seizure/fitting
calls. In particular, and in relation to code 12D02 calls (post 19.6.19) the
requirement for a healthcare professional to call back after 20 minutes of
continuous fitting to trigger a call upgrade from Amber 1 to Red.

In an e-mail from of 17/10/19 © 7.11 and read to the
Court, it was confirmed that the question is not currently asked of the
caller to WAST, how long has the patient been fitting?

This would appear to be a crucial piece of information in order to ascertain
as accurately as possible, the known timing of the onset of the fit, for the
purposes of determining when the 20 minutes elapsed. E.g. if itis known
that the patient has already been fitting for 10 minutes, then the advice to
call back should be in 10 minutes hence. If the fit has just commenced,
then obviously, that advice can be for a 20 minutes call back.

CadeirydaChair Martin Woodtord
Prf Wetttredwr/Chief Executive: Jason Killens

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The improvement plan attached includes actions that the Trust is considering
in relation to the code set 12C02. One of the actions will be to consider whether
the Trust will move the code set into the Red (Immediately Life Threatening}
category. This has already been previously been discussed and considered
through the Clinical Prioritisation Assessment Software (CPAS) group, and is
scheduled for further discussion in March 2020.

However, before making any changes to code sets, the Trust has to consider
the impact that such a change may have. This will include, for example what is
the clinical rationale for making the change, an evidence base, patient
outcomes and any potential detrimental effect the change may have on other
codes. Also, the Trust is considering undertaking some external modelling
through Optima (which is software modelling that is used to help make better
decisions in health), on the potential performance impact of such a change may
have. This will include the effect this change may have on Amber responses, if
12C02 moves into the Red category.

In addition, the Trust has also changed the guidance for prolonged fitting. This
guidance reflects that the call takers should stay on the line with all callers,
rather than asking Health Care Professional) (HCP) callers to ring back (I attach
a copy of the current guidance for your reference) and calls should be escalated
to a Red, in order to ensure the immediate dispatch of a suitable resource.

The wider issue of whether a response from a healthcare professional (to
a question(s) posed by a call handler) that the patient is not maintaining
his/her airways should itself trigger/categorise a continuous red code.
The evidence of | at the Inquest, was that such a
scenario was of the highest clinical priority, as the patient had a high risk
of cardiac arrest in such circumstances. There appeared some tension in
the evidence surrounding the 12D01/02/03 categorisation as to which
code would be triggered on the volunteering, or otherwise of this
indication from the caller.

To inform my response, it will be helpful to provide some background
information. Prior to 2014 all Health Care Professional (HCP) callers were
asked if the condition of their patient posed an immediate threat to the patient's
life. If the HCP gave a positive response, this resulted in an immediate Red 2
(now Amber 1) response being generated without any further questions being
asked. Unfortunately this resulted in HCP calls being given higher priority than
patients in a similar or worse clinical condition. The unintended consequence
could result in other patients having adverse clinical outcomes.

To overcome this, the Trust now use the questions through the Medical Priority
Dispatch System (MPDS), to ensure that all patients across Wales are treated
with parity, including HCP requests. HCP calls are consequently prioritised as
Red where it is clinically appropriate.

There are rare occasions, as a result of this change, when the MPDS will not
detect the urgency of some, relatively rare, asymptomatic conditions. However,
to overcome this the Trust has introduced within the Clinical Contact Centre

(CCC) a Clinical Support Desk with dedicated clinicians. Introducing clinicians
into this environment enables HCP callers to request to have a clinician to
clinician conversation if they feel their patient warrants a higher priority of
response.

The actions to be taken when the urgency of the response after triage does not
match the expectations of the booking HCP due to the presenting condition
include:
1. Documenting any clinical information that has been provided by the
HCP;
2. If a CCC clinician is available, to place the HCP call through to the
CSD;
3. If no clinician is available the Emergency Medical Dispatcher (EMD)
will immediately raise the call with their supervisor, or Duty Control
Manager (DCM), if no supervisor on duty. The Supervisor or Duty
Control Manager (DCM) will tag the call for review by a clinician and
ensure a clinician is informed.

Whether a pathway exists, or should be created for updating G4S — the
operators of Parc Prison with changes implemented by the WAST
affecting call prioritisation. This is likely to have the benefit of ensuring
that healthcare professionals at the prison are fully aware of what is
expected of them in an emergency call to WAST and what response can
be expected from WAST at the time an emergency call is placed.

As an All Wales Ambulance Trust we provide an all Wales service. The Trust
operates three regional CCC's who work virtually across Wales, not servicing
individual Health Boards or boundaries, with calls being answered by the
availability of call handlers, rather than by geographical location of the patient.
Therefore, the handling of emergency calls received, is pan Wales, without
regional and or local variations. This principle is also true across all of the HM
Prisons across Wales.

Therefore, as requested, the Trust has considered if it would be appropriate to
create bespoke pathways for Parc Prison or to introduce some local variation.
However, after some consideration it is believed that this would not be an
appropriate way forward. All emergency calls are unique in nature and will
require a different response based on clinical need and the presentation of the
patient. To introduce local variation could also potentially have adverse
consequences for patients across Wales.

However, | can provide you with assurance that quality improvements and
changes have been made within the Trust. | can confirm that we have improved
the way in which the Trust and HCP callers are able to communicate. The Trust
has increased the number of clinicians on the CSD. Further to this the Trust
has introduced 2 new roles within the CCC and the CSD. The first role being a
Call Taker Supervisor is a new role introduced in November 2018, with the
purpose of supporting the CCC operating 24 hours a day 7 days per week. The
second role is a shift lead within the CSD who will have oversight of the patients
waiting on the 999 queue. This clinician can now view a list or queue of calls

waiting for clinical input and has the ability to filter HCP calls waiting and can
bring them to the forefront. In addition, with this expansion, we have been able
to put escalation arrangements in place for HCP callers who require to have an
urgent clinical discussion.

4, Whether there is, or should exist, a clear pathway for dialogue between
the Princess of Wales Hospital Emergency Department clinicians and
WAST in relation to best practice for call categorisation. In particular,
whether there should be regular input from the emergency department
consultants at the Princess of Wales Hospital into the CPAS group for the
purposes of assisting in relation to the appropriate categorisation of calls.

Whilst the Trust would welcome engagement from clinicians from Princess of
Wales Hospital, the Trust provides an all Wales ambulance service
commissioned by the 7 Health Boards across NHS Wales. | can assure you
that the CPAS group which is chaired by a Senior Medical Consultant (Assistant
Medical Director) has a wide and varied clinical membership including
representation from Patient Safety. The group also has a robust governance
framework in place to ensure clinical decisions are documented.

However, | am able to provide you with assurance that the Trust uses the
international Medical Priority Dispatch System (MPDS) which is an
international, evidence and research based system used across the world to
ensure that the calls are categorised and correctly prioritised, ensuring that
patients receive the correct emergency response. This is how all Ambulance
Trusts provide assurance of best practice.

| would again like to extend my sincere condolences to Mr Mclean's family on their sad
loss. | would also like to extend the offer to meet with you to discuss our response in
more detail and to provide you with any further assurance you may require regarding
our commitment to continuous improvement to support the prevention of future deaths.

Yours sincerely

Jason Killens
Chief Executive

Enc: Guidance Document - Prolonged Fit