William Oliver

4

2Q NOV 2019 Se NHS

Blackpool Clinical Commissioning Group
Fylde and Wyre Clinical Commissioning Group

Blackpool Office Fylde and Wyre Office
The Stadium NHS Wesham Offices
Seasiders Way Derby Road
Blackpool Wesham

FY1 6X PR4 3AL

Tel: 01253 951200 Tel: 01253 956400

www. blackpoolccg.nhs.uk ww. fyldeandwyreccg.nhs.uk
18" November 2019

FAO: Ms Joanne Kearsley, Senior Coroner
Manchester North Coroner Area

Coroners Service, Phoenix Centre

L/Cpl Stephen Shaw MC Way

Heywood

Greater Manchester

OL10 1LR

Dear Ms Kearsley,
Re: Response to Regulation 28 report in relation to William Oliver

We are responding to the matters of concern raised following the death of William Oliver at his home address
of 42 Earles Lodge, Albert Street, Failsworth, on 1 November 2018. The Ambulance Commissioning Team,
hosted at Blackpool CCG, is responsible for commissioning North West Ambulance Service (NWAS) on behalf
of the 31 North West CCGs.

Coroners Concerns:

1. Meal Break Policy and Shift Rostering

During the course of the Inquest the Court heard evidence as to the demand experienced by NWAS during the
night of 31 October-1*t November. One of the reasons for difficulties in allocating resources was directly
attributed to the meal break policy. In short, the issue being that each crew has to take a 30 minutes meal
break within their meal break window. This has been highlighted in other serious incident investigations. In this
case there was a significant reduction in the number of vehicles able to be allocated during the time Mr Oliver
had contacted NWAS. The court heard that this policy has been under review, but that no changes had yet
been implemented.

Ambulance Commissioning Team, Blackpool CCG response:

As part of the NHS Standard Contract 2019/20 Service Development Improvement Plan Blackpool CCG has
emphasised the importance of a Roster Review and have included the Roster Review in commissioner
requirements to support and gain assurance from NWAS in its implementation. The roster review will use
detailed demand profiling data to align the entire workforce to meet the expected service demand and will be
reviewed on an annual basis. As part of these changes the meal break policy will be reviewed to ensure that it
does not compromise the effectiveness of this workforce profiling. Implementation in Greater Manchester is
planned for January 2020.

Blackpool CCG Chairman - Roy Fisher Chief Clinical Officer - Dr Amanda Doyle OBE Fylde and Wyre CCG Chair - Mary Dowling

2. Times at Greater Manchester Hospitals

Another contributing factor to the decreased availability of ambulances on the 31% October-1* November was
the turnaround times at hospitals in the Greater Manchester area. Whilst hospitals were busy the turnaround
times at Manchester Royal Infirmary, North Manchester General, Royal Oldham, Salford Royal and Stepping
Hill Hospitals were all particularly higher than anticipated with numerous ambulances delayed for over an hour.

Ambulance Commissioning Team, Blackpool CCG response:

Recognising that handover and turnaround performance is a whole system responsibility there has been
significant system-wide focus on improvement. It formed part of the NWAS Performance Improvement Plan
and in 2018 the North West Handover Stakeholder Engagement group was established.

A collaborative programme called ‘Every Minute Matters’, was undertaken over winter 2018/19 with six
identified hospital sites to deliver sustained 30 minute performance for handover (the national target). The
sites were chosen because they had challenged performance and collectively represented a significant
proportion of ambulance arrivals due to their size, so improvements at these sites would have a
disproportionate impact on the whole North West. The programme’s aim was to reduce hospital handover
times by using improvement methodology. All hospitals participated in learning workshops and undertook rapid
tests of change. All six sites focused on understanding their processes and data and using measurement to
drive improvement. The collaborative approach has fostered sharing of good practice but also friendly
competition between the sites, with reduction in handover times being achieved. One Greater Manchester
Hospital was included in this cohort..A further eight hospitals have started this programme at the end of
October 2019 including two further Greater Manchester hospitals. The intention is for:this programme to be
implemented at all North West Emergency Departments, including Greater Manchester hospitals, to improve
handover times and therefore increase the availability of ambulances to respond.

The stakeholder group has recently been superseded by a North West Handover Improvement Board, co-
chaired by the NHSEI Director of Improvement and the NWAS Chief Executive. This Board will provide
leadership and direction to system wide handover improvement work, particularly within A&E Delivery Boards.

We would like to thank you for drawing attention to these important matters and providing further impetus for
system-level change that will reduce the future risk to patients. We hope that our response has provided
sufficient assurance that these themes had been identified and that a programme of work is in place to
address them. Should you require any further information please do not hesitate to contact us.

Yours sincerely,

Yvonne Rispin Magnus Hird
Director of Ambulance Commissioning Regional Clinical Lead

ah From Edward Argar MP

D epartm ent Minister of State for Health
of Health & 39 Victoria Steet
Social Care SW1H OEU

020 7210 4850

Our Ref: PFD-1190331

Ms Joanne Kearsley

HM Senior Coroner, North Manchester

Coroner's Service

Phoenix Centre

L/Cpl Stephen Shaw MC Way (formerly Church Street)
Heywood OL10 1LR

rt
28 January 2020

Dn uke,

Thank you for your correspondence of 12 September 2019 to Matt Hancock about the
death of Mr William Oliver. | am responding as Minister with responsibility for urgent and
emergency care and | am grateful for the additional time in which to do so.

Firstly, | would like to say how saddened | was to read of the circumstances of Mr Oliver's
death and | extend my sympathies to his family and loved ones.

it is important that we look to make improvements where we can to ensure safe and high
quality healthcare services. | am informed that the North West Ambulance Service NHS
Trust has acknowledged that on this occasion, it did not provide the right care, as quickly
as it should have done.

In preparing this response, Departmental officials have taken advice from the Association
of Ambulance Chief Executives (AACE) and NHS England and NHS Improvement.

On the matter of meal breaks and shift rostering, paramedic meal breaks and shift pattern
arrangements are operational matters for individual ambulance trusts and there is no
national ambulance meal break policy. Meal break requirements are set out in
employment law (including the Working Time Directive) and NHS ambulance trusts
develop their own policies to ensure compliance with the law.

| am advised that all ambulance services are aware of the need to stagger meal breaks as
much as possible and to regularly review rostering systems. When on meal breaks, staff
are effectively off duty and are free to leave their working environment and use the time as
they wish. However, ambulance trusts have arrangements in place to enable staff to elect
that, on a voluntary basis, they are willing to be disturbed during breaks to attend life-
threatening incidents.

| am assured that all ambulance trusts are aware of their responsibilities in this area and
regularly review rostering arrangements to ensure they are robust and optimised to meet
current demand patterns.

lam advised that following a review, the North West Ambulance Service is looking to
introduce new shift rostering and meal break arrangements to better meet resource
demands and has benefitted from increased investment from commissioners for an
additional 250 paramedics.

In relation to ambulance handover delays, we are clear that patient handovers must take
place within agreed timeframes. NHS England and NHS Improvement are taking a joint
approach to improve performance, including:

e The identification of regional leads for handover performance, holding NHS
providers to account for improved performance;

e Emergency Care Improvement Teams supporting the most challenged acute trusts
with identified handover delay issues to improve performance;

e The issuing of revised, detailed hospital handover guidelines, focussing
responsibility on the wider system to address handover delays, including clear
escalation procedures; and,

e Improved monitoring and reporting of patient handover delays.

The NHS Standard Contract! stipulates that patient handovers need to be completed
efficiently within 15 minutes to allow ambulance resources to be returned to service quickly
(ambulance crews then have a further 15 minutes to make their ambulance ready to
respond to new calls).

The Department has made the AACE aware of the concerns in your report. The AACE
acts as a national co-ordinating voice on issues of policy and practice for ambulance trusts
and | am advised that the AACE takes seriously the learning that can be gained from
Prevention of Future Deaths reports. The AACE has mechanisms in place to bring
matters of concern to the attention of ambulance trusts in England and to promote the
development of good practice.

Finally, we know that there is high demand for ambulance services. Including calls
transferred from NHS 111, ambulance services deal with more than 11 million 999 calls
every year. However, we are taking significant action to improve ambulance services at a
regional and national level.

Nationally, we have implemented an improved ambulance performance framework across
all ambulance trusts in England that prioritises responses to the sickest patients, while
helping to reduce long waits and ensuring patients receive the most appropriate response
for their condition. This includes reducing unnecessary journeys to hospital by safely
treating at scene where clinically appropriate which in turn increases the availability of
ambulances to respond to other incidents.

' https://www.england.nhs,uk/wp-content/uploads/2019/03/8-NHS-Standard-Contract-Technical-Guidance-1920-v1_pdf

| hope this response is helpful. { am grateful to you for bringing these matters to my

attention.
 aaiommnt
qoAy

EDWARD ARGAR MP

Our services: 
Emergency and urgent care  
Non-emergency patient transport  
NHS 111 

Ms J Kearsley 
HM Senior Coroner 
Manchester North Coroner’s Service 
Phoenix Centre 
L/Cpl Stephen Shaw Way 
Heywood 
PL10 1LR 

10 December 2019 

Dear Ms Kearsley, 

Inquest touching the death of William Oliver 

Headquarters 
Ladybridge Hall 
399 Chorley New Road 
Bolton 
BL1 5DD 

Tel: 01204 498400 

www.nwas.nhs.uk 

I  write  in  relation  to  the  Regulation  28  report  that  you  issued  at  the  conclusion  of  the  inquest  touching  the 
death of William Oliver. 

I  know  that  you  will  share  this  response  with  Mr  Oliver’s  family  and  I  firstly  want  to  express  my  sincere 
condolences to his family. 

The  Trust  is  committed  to  providing  the  right  care,  at  the  right  time  and  in  the  right  place  but  I  fully 
acknowledge  that  on  this  occasion,  the  Trust  did  not  provide  Mr  Oliver  with  an  ambulance  as  quickly  as  it 
should have done and I am extremely sorry for that. The Trust takes all adverse events very seriously and the 
Trust undertook a thorough internal review into the attendance on Mr Oliver.  

Through the Regulation 28 report you have requested that NWAS consider your matters of concern and have 
suggested that action is taken to prevent future deaths. By this letter, I will address those concerns as far as I 
am able to do so. 

1.  Meal Break Policy and Shift rostering 

The Trust needs to find a balance between  maintaining resource availability  in order to respond to incidents 
whilst at the same time complying with health and safety legislation and ensuring the crews are appropriately 
dined and rested in order to deliver a high standard of care.  

Roster review 

Through the written and oral evidence which was before you during the inquest, you are aware that the Trust 
has been working in partnership with external consultants and is undertaking a wholesale review of the Trust’s 
shift  and  roster  arrangements.  The  roster  review  has  been  ongoing  since  May  2019  and  has  required 
consultation  with  both  the  Trust’s  employees  and  Unions  since  the  changes  which  the  review  will  effect  are 
significant and will substantially change the operational working  arrangements by staggering  shift start times 
and shift lengths.   
Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton, BL1 5DD 

Chairman:  Peter White 

Chief Executive: Daren Mochrie QAM 

 
 
 
                                                                                                                           
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  roster  review  allows  the  Trust  to  maximise  the  availability  and  use  of  existing  resources,  identify  where 
investment is best placed and also lead to a redistribution of its fleet so that vehicles are located in the areas 
where they are needed most. 

Together with our lead commissioners, the Trust is committed to completing the roster review and particularly 
the use of detailed demand profiling to align the workforce to meet the expected levels of demand. 

The  Trust  plans  to  commence  the  implementation  of  the  revised  shift  start  times/lengths,  within  Greater 
Manchester, in February 2020. 

Pilot: Meal Break Policy 

In  addition  to  the  roster  review,  in  July  2019  following  consultation  with  our  commissioners,  the  Trust 
commenced  an  executive  lead  review  of  the  meal  break  policy  which  has  seen  the  formulation  of  a  focus 
group encompassing representatives from HR, operations and the medical directorate. 

The  focus  group  has  reviewed  the  current  working  practices  and  the  control  room  guidance  linked  to  meal 
break management. Within the Emergency Operations Centre (EOC) the task of managing meal breaks falls to 
the  dispatchers  who,  during  periods  of  high  demand,  naturally  focus  on  the  management  of  incidents  and 
ambulance dispatch which, consequently, leads to crews being dined outside of the meal break window.   

Through the  work  of  the focus group,  a  pilot  has  been  devised  which  will  take  the  management of the meal 
break away from the dispatcher and also see a mandatory staggered stand down of resources throughout the 
meal break window. 

The pilot has received approval from the Trust’s Executive Leadership Committee and is already being trialed 
from  within  the  Cheshire  and  Mersey  EOC.  The  intention  is  that  through  this  mandatory  stand  down,  the 
number  of  crews  being dined  outside  of the meal  break  window  will  be  reduced  to the  lowest  possible  level 
and maintain resource availability. 

 Additional Investment 

Aside from the work highlighted above, following the demand and capability assessment that was referred to in 
the Trust’s written evidence, the Trust  has received significant additional investment from its commissioners. 
As a result of that investment, the Trust will be putting an additional 250 paramedics into the service between 
now and March 2020. 

I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed 
you concerns by this response. If it assists, the Trust will be more than willing to provide you with an update at 
the conclusion of the pilot. 

If you require any further information or clarification, please do not hesitate to contact me or the Trust’s Head 
of Legal Services. 

Yours sincerely,  

DAREN MOCHRIE QAM, MBA, Dip IMC RCSEd, MCPara 
Chief Executive 

- 2 -

Ss ‘and ‘pro les. you. with. the assurance thatthe
atients: Please ey not t hesitate _

_ Chief Executive a

"Page 2 of 2