Karen Bingham

OFFICIAL SENSITIVE  

Regulation 28: Report to 
Prevent Future Deaths – Karen 
Jane Bingham  

Document details  

Authorising Officer  

Author  

T/Assistant Chief Constable 

Completed: 12/5/2020 

Distribution  

HM Assistant Coroner Caroline Topping 

Executive Summary:  

This report has been written in response to actions outlined within section 5 of HM Assistant Coroner’s 
regulation 28 report following the investigation and inquest into the death touching Karen Jane Bingham.  

HM Assistant Coroner’s request for response to key areas of concern as follows: 

1.  Police training in respect of mental health does not provide information as to the type of 

behaviours associated with common mental health conditions. 

2.  Those responsible for the dispatch of emergency services in the police and ambulance services do 
not have a sufficient understanding of the triaging and dispatching processes used by each other’s 
service nor their response times. 

Surrey Police response  

(In respect of the order in which the points appear above): 

1.  Guidance is currently available via an APP on all officers’ Mobile Data Terminals entitled “Mental 

Health Guide”. This will be updated to ensure the comprehensive section on signs and indicators of 
mental health conditions is at the top of the page and the first thing available for officers to refer 
to. This will be closely followed with contact details for further assistance and advice which includes 
out of hours service available for all officers when faced with a potential mental health situation. 
The guidance also includes initial engagement advice, flowcharts detailing process and advice for 
officers who are considering sectioning an individual.  

  
  
  
 
  
 
  
  
 
 
  
 
 
 The Force is also publishing further details in relation to the roll out of mental health first aiders via 
the Occupational Health Unit which will give a clear list of support available to officers to help them 
identify and deal with mental health issues both with their own staff and when dealing with the 
public. Line managers are also to be delivered training on recognising mental health conditions 
which they will cascade to their own teams.  

The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day 
training session for all of their staff on common mental health conditions later in 2020 to help those 
dealing with the public over the telephone recognise signs and symptoms.  

There is a revised online Mental Health training package which is to be mandated for all officers 
and staff to refresh their knowledge and skills in this area, including recognising common 
behaviours in those with mental health conditions. This will feature an input from SECambs Clinical 
Operations Manager on NHS Pathways and response times.  This will also be supplemented by 
training input at officers’ annual officer safety refresher training during the autumn. 

2. 

In the summer and autumn of 2018 (since Karen’s death) all staff from the Contact Centre and 
Force Control Room (resource dispatch) received training from South East Coast Ambulance 
(SECambs). This included input on NHS Pathways (as described during the inquest), Ambulance 
Response Programme (categories of response and associated time frames) and their Operational 
Business Plan Surge (which protects calls with the highest clinical need where there is excess 
demand). 

To supplement the training a number of staff “exchanges” between Surrey Police and SECambs to 
gain a better understanding of the roles of their respective contact and dispatch functions.  

A quarterly meeting is held between the senior managers of Surrey Police’s Force Control Room, 
and SECambs Emergency Operations Centre to discuss any matters which may impact respective 
services including any themes from incident reviews (albeit these meetings have been postponed 
during the current Covid-19 pandemic). 

A new Decision Support Flowchart, to help police officers and Contact Centre staff identify the 
appropriate NHS Pathway when dealing with members of the public (e.g. 999, 111, GP etc), has 
been agreed across Surrey, Sussex and Kent with a planned implementation date of October 2020.

South East Coast Ambulance 
Service NHS Foundation Trust 
Nexus House 
Gatwick Road 
Crawley 
RH10 9BG 

0300 123 0999 

Ms Caroline Topping 
HM Assistant Coroner for Surrey 

By email only 

11 May 2020 

Dear Madam 

Karen Bingham deceased 

I write in response to the Regulation 28 Prevention of Future Deaths Report that you issued 
in this case on 30 March 2020.  I was very sorry to hear of Ms Bingham’s passing and I 
would like to pass my personal condolences to Ms Bingham’s family. 

I am not able to respond to the first matter of concern raised in your report as this concerns 
Surrey  Police  alone.  I  therefore  confine  my  response  to  the  second  matter  of  concern, 
namely: 

“Those responsible for the dispatch of emergency services in the police and ambulance 
services do not have a sufficient understanding of the triaging and dispatching processes 
used by each other’s service nor their response times”. 

I would like to break your concern down into two areas: 

1.  SECAmb’s dispatch staff’s knowledge of police dispatch procedures 

  and 

I understand that evidence was given to the inquest by two of my senior managers, 
  as  to  how  SECAmb’s  Emergency  Operations  Centre 
(“EOC”)  functions  so  I  do not  intend to  repeat  that here.  From  that  evidence,  the 
Court is aware that a national triage system called NHS Pathways (“NHSP”) is used 
in our EOC to triage and categorise calls.  NHSP arrives at a “disposition” – a call 
categorisation. Our Resource Dispatcher will see the incident immediately when the 
area of the incident becomes apparent and can assign a resource either immediately 
for  a  Category  One  (“C1”)  call  or  after  or  during  triage  for  other  categories.  This 
visibility allows the dispatcher to start planning a suitable resource to send to the 
patient during triage. The dispatcher will assign an ambulance resource when  an 
appropriate  vehicle  becomes  available  in  a  reasonable  vicinity  of  the  incident.  
Resources  are  primarily  assigned firstly  according  to  urgency  (C1  calls first,  then 
category 2 etc) and secondly, within a category, on the length of time the call has 

  Chairman: David Astley 

                   Chief Executive Officer: Philip Astle 

 
 
 
 
 
 
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 been waiting (the oldest C2 call will be assigned a resource before the second oldest 
etc).  There are limited circumstances in which a call can be elevated to a higher 
priority than its place in the queue of outstanding calls.  Dispatchers are supported 
by  nurse  and  paramedic  Clinical  Supervisors,  coordinated  by  a  Clinical  Safety 
Navigator,  who  are  assigned  to  oversee  ‘Clinical  Prioritisation’  of  all  incidents 
awaiting  resource  allocation.  Clinical  Prioritisation  includes  undertaking  clinical 
reviews of individual incidents, undertaking welfare checks, calling back cases for 
enhanced  triage,  upgrading/downgrading  and  prioritising  individual  cases  within 
their existing categorisation.  Furthermore, dispatchers have a route of escalation 
through  a  Dispatch  Team  Leader  (DTL)  and  Clinical  Supervisor  to  highlight  any 
individual incidents where they have reason for concern. 

Whether another emergency service is attending an incident and in what timeframe 
are not factors that would normally influence a dispatcher’s decision making. There 
are a very limited number of scenarios in which knowledge of the type and number 
of co-responders from other services being assigned may be of use, for example: 

• 

If multiple police resources were attending a patient experiencing a mental 
health illness and were needing to restrain them, we might consider Acute 
Behavioural Disturbance and think about sending a Critical Care Paramedic. 
•  An  incident  involving  multiple fire appliances  would  be  a  consideration for 

Hazardous Area Response Team allocation. 

Our  dispatchers  are  not  specifically  trained  in  police  triaging  or  dispatching 
processes  because  such  knowledge  would  so  rarely  factor  into  their  dispatching 
decisions, which are based on clinical need. 

As  mentioned  above,  calls  awaiting  assignment  of  an  ambulance  resource  are 
under  constant  review  by  a  clinician,  who  does  have  the  ability  to  alter  the 
categorisation or priority of a call.  The decisions of the clinician are made on clinical 
grounds; factors such as history, environment, load on our system are also taken 
into  account.  Knowledge  of  estimated  arrival  times  of  other  emergency  services 
would not influence these clinical decisions in the vast majority of cases. 

Where there is concern between agencies, the issue can be raised at an operational 
or  tactical  management  level  where  the  principles  of  JESIP  will  be  applied.  Put 
simply, the Police Operational Commander can, and does, talk to the EOC Manager 
or Clinician Supervisor to discuss the incident. 

In  light  of  the  above,  I  consider  that  the  knowledge  of  my  EOC  staff  of  police 
dispatching  processes  is  sufficient  at  present  to  enable  them  to  carry  out  their 
functions safely and appropriately. 

2.  Police dispatch staff’s knowledge of SECAmb’s dispatch procedures 

 gave evidence to the inquest of the actions taken by SECAmb to ensure 
that  our  police  colleagues  are  aware  of  our  call  categorisations  and  response 
targets.  At  the  time  the  Ambulance  Response  Programme  was  rolled  out  in 
SECAmb (on 22 November 2017) a comprehensive document was prepared for our 
partner organisations and distributed to them. This includes the three police forces 

Chairman: Sir Peter Dixon 

   Acting Chief Executive: Geraint Davies 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 with  whom  we  principally  work:  Surrey,  Sussex  and  Kent.  We  created  and 
disseminated  a  further  document  for  our  partner  agencies  explaining  our  Surge 
Management  Plan,  including  information  on  how  we  triage/prioritise  calls,  ARP 
response targets, SMP triggers and our actions. We also have in place a system for 
notifying  Police  Force  Control  Rooms  by  email  when  we  reach  the  levels  of  our 
Surge Management Plan whereby there is a substantial risk that we will struggle to 
reach our target response times. 

SECAmb rely on our police partners to disseminate internally the information that 
we provide.  It is for each force to ensure that all relevant materials are cascaded to 
all those who need to know of their contents. 

Notwithstanding  the  efforts  we  have  previously  made  to  ensure  our  police 
colleagues are aware of our processes, we have considered, in light of this case, 
  and  the  EOC  Operating  Unit  Manager 
whether  we  could  go  further. 
responsible for dispatch 
 are in the early stages of a review of our Surge 
Management  Plan.  We  consider  that  it  would  be  constructive  to  involve  all  three 
police forces in our area as part of that review to discuss possible joint actions that 
could be taken when certain levels of stress on our system are reached.  There are 
many options that we consider worth joint discussion, some of which could lead to 
closer working of our respective control rooms. 
 will  work 
with  our  Blue  Light  Collaboration  Manager  to  liaise  with  our  police  colleagues  to 
explore  opportunities  for  closer  collaborative  working. Whilst  I  do  not  have  a  firm 
timescale for this review, particularly in current circumstances, I would very much 
hope that it will be concluded and implemented before the end of this year. 

If I can assist you further in relation to any of the above, please do not hesitate to contact 
me. 

Yours sincerely 

Philip Astle 
Chief Executive Officer 
South East Coast Ambulance Service NHS Foundation Trust 

Chairman: Sir Peter Dixon 

   Acting Chief Executive: Geraint Davies