Vhari Ingall and Mary Johnson

David Ridley
HM Senior Coroner
for Wiltshire and Swindon

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Chief Executive

South Western Ambulance Trust
Trust Headquarters

Abbey Court

Eagle Way

Exeter

Devon

EX2 7HY

Executive Officer

The Association of Ambulance Chief Executives
MBF

GG322

30 Great Guildford Street

London

SE1 OHS

CQC National Customer Service Centre
Citygate

Galtowgate

Newcastle upon Tyne

NE1 4PA

CQCinquestsandCoroners1@cqc.org.uk

CORONER

lam David Ridley, Senior Coroner for Wiltshire and Swindon

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST
On the 16 December 2019 | commenced an investigation into the death of Mary Grace

JOHNSON (aged 98) which occurred during the early hours on 10 December 2019. | opened an
Inquest into her death on the 4 March 2020.

On 27 March 2020 | commenced an investigation into the death of Vhari INGALL (aged 54) and

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

have authorised a post mortem examination with a view to confirming the cause of her death.
Mrs Ingall’s death was confirmed by an attending paramedic at 0105 earlier that day on 27
March 2020.

The cause of death in relation to Mary JOHNSON which is subject to final determination at
Inquest, but which | have to say is unlikely to change, is tramadol toxicity.

In both of these cases, they have involved paramedic attendance and an awareness and belief
that both of these individuals had separately taken an overdose by way of self-harm.

In relation to Mrs. Johnson it is believed that she was found at her home at|

Christian Malford, Chippenham, Wiltshire on the 9" December 2019 by her daughter with a glass
with white powder residue in it and a note explaining that Mrs. Johnson “had a good life and
wanted to die at home’, 2 further notes were located in the bedside table. Paramedics were
called to the property and they produced an advanced directive and | also understand that there
was a Do Not Resuscitate form. Some of Mrs. Johnson’s family, who were present at the time
were insistent that she should not be taken to hospital and the paramedics sought advice from
their control room as to what to do and the decision was taken to leave the lady to die at home.
The SWAST report refers to “...it was a potential best interest decision to leave the patient on
scene and allow for natural death.”

|_understand in relation to Ms. Ingall, following the arrival of Paramedics at her home a

Royal Wootton Bassett, Wiltshire that despite their encouragement for her to go to
hospital she refused. It was believed that Ms Ingall had taken an overdose of medication. _ It
would appear that there were mental capacity concerns. The Paramedics sought Police
involvement but shortly after police arrival it is understood that she became unresponsive. The
Paramedics were aware again of a Do Not Resuscitate form and when she became
unresponsive did not carry out any form of resuscitation measures on the basis of its existence.
It is believed that Ms Ingall has died as a result of excess medication and this is currently being
investigated.

CIRCUMSTANCES OF THE DEATH
See above

CORONER’S CONCERNS

Even though neither of these cases have proceeded to a final Inquest hearing in accordance
with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future
deaths can be made if evidence comes before the Coroner that causes a concern and triggers
the Coroner's duty to submit such a report if the Coroner thinks it is appropriate. | am of the view
that this duty has now been triggered because the death of Ms. Ingall raises the same issue and
concern that | have following the death of Mrs. Johnson. The concern is that the Do Not
Resuscitate document applies to allow specifically a natural death. We know that Mrs. Johnson
did not die a natural cause of death and there were sufficient information indicators at the scene
and the Paramedics were aware that she had taken, more likely than not, an overdose. The
same appears to be the case with Ms. Ingall although this is subject to confirmation following the
post mortem examination. A person dying as a result of self-harm and as a result of an
overdose cannot if any way whatsoever be regarded as a natural death, it is my view and
concern that Paramedics are being placed in a difficult position as well of those that they are
responsible for caring for if they do not intervene appropriately. It may be the case at hospital
and potentially with the involvement of mental health professionals that a decision is taken to
withdraw treatment, but | am concerned, especially having regard to Article 2 of the European
Convention of Human Rights that that decision is not taken by frontline Paramedics and | would
ask you to urgently review the instructions and guidance given to your frontline Paramedics in
these situations.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

to take such action.

This is a revised report to Prevent Future Deaths which is being sent to additional recipients as |
now have a genuine belief that this may potentially be a wider issue nationally and not just
limited to the NHS Ambulance Trust covering the South West.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, unless |
have extended this period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

| have already granted SWAST an extension until 26 July 2020, at their request, but | am now
aware from recent correspondence that their investigations will not be concluded until early
August 2020. Responses are therefore to be received by 1 September 2020 unless a further
extension is requested and granted by me.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Person,
Daughter of Mrs. Johnson

Sister of Ms. Ingall

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

Dated 7 May 2020 .

signature Ss ait Senior Coroner for Wiltshire & Swindon

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

24 September 2020 

BY EMAIL 

David Ridley 
Senior Coroner for Wiltshire and Swindon 

Association of Ambulance Chief Executives 

E:  

T:  020 7118 

@aace.org.uk 
W:  www.aace.org.uk 

Dear Mr Ridley 

REGULATION 28:  JOHNSON AND INGALL 

I am writing in response to the Regulation 28 report to prevent future deaths touching the deaths 
of Mary Grace Johnson and Vhari Ingall which you issued on 7 May 2020 to the Association of 
Ambulance Chief Executives (AACE).  

AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide 
ambulance services with a central organisation that supports, co-ordinates and implements 
nationally agreed policy. Our primary focus is the ongoing development of the English ambulance 
services and the improvement of patient care. It is a company owned by NHS organisations and 
possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee 
UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not 
constituted to mandate or instruct ambulance service however it has national influence via the 
regular meetings of ambulance Chief Executives and Trust Chairs along with a network of 
national specialist sub-groups. One of its specialist sub groups is the National Ambulance Service 
Medical Directors (NASMeD); this response is from AACE having been informed by NASMeD.  

Your concern is that the Do Not Resuscitate document applies to allow specifically a natural 
death, and that a person dying as a result of self-harm, specifically overdose, cannot be regarded 
as natural.  In this circumstance the decision not to resuscitate should not be left to frontline 
paramedics. You have asked AACE to review the guidance provided to paramedics in these 
situations.  The JRCALC guidelines do include guidance on resuscitation in relation to patients 
that may have a DNACPR form. 

With regard to DNACPR forms, there is specific guidance on validity, including the statement that 
the DNACPR form should “explicitly identify the circumstances in which the DNACPR 
recommendation applies”.  Application of a DNACPR instruction should not occur until the patient 
is in need of resuscitation, ie. until they are in cardiac arrest.  The presence of a DNACPR form in 
isolation should not deter a paramedic from treating a patient who is still alive, and if the cause of 
a cardiac arrest is amenable to immediate treatment, eg. choking, then a resuscitation attempt 
should be initiated.  There are also a number of circumstances contained in the guidance that 
require paramedics to consider transporting patients to hospital without delay, and with 
resuscitation ongoing, due to being potentially amenable to treatment.  These include instances of 
suspected drugs overdose or poisoning. 

In any event, when a patient lacks capacity to make their own decisions, paramedics are 
encouraged to make best interest decisions based on clinical presentation, likely futility of a 

Chairman:  

 QAM, MBA, Dip IMC RCSEd, MCPara 

Managing Director:  

 OBE 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 resuscitation attempt, and the patient’s wishes, if known.  The presence of a DNACPR form 
assists in reaching that decision, and reference to the JRCALC guidelines should be made. 

AACE, through NASMeD, has undertaken to review the JRCALC guidelines relating to the 
circumstances in which resuscitation attempts should not be undertaken, and the application of 
DNACPR forms, and strengthen the guidance in an attempt to prevent recurrence of these 
unfortunate situations.  I trust that this response addresses your concerns. 

If I may be of further assistance, please do not hesitate to make contact.  

On behalf of AACE, I would like to extend our sincere condolences to the family of Mary Grace 
Johnson and Vhari Ingall 

Yours sincerely 

 OBE 

Managing Director 

Chairman:  

 QAM, MBA, Dip IMC RCSEd, MCPara 

Managing Director:  

 OBE

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 03000 616171 

HM Coroner Mr. David Ridley 

11 March 2021 

Care Quality Commission (CQC) 
Our Reference: 

Dear HM Senior Coroner 

Prevention  of  future  deaths  report  following  the  Inquest  into  the  death  of 
Mary Grace Johnson and Ms. Vhari Ingall. 

Thank you for your Regulation 28 report to prevent future deaths issued following 
the inquest into the sad death of Mary Grace Johnson and Vhari Ingall.  

The role of the CQC 
The role of the Care Quality Commission (CQC) as an independent regulator is to 
register health and adult social care service providers in England and to inspect 
whether  or  not  the  fundamental  standards  are  being  met.  The  legislation  that 
governs  this  includes  The  Health  and  Social  Care  Act  2008  and  associated 
regulations. 

Prevention of Future Deaths Report 
In the regulation 28 report, you have asked CQC to consider the following concern: 

I would be grateful if you would please consider as part of your inspection 
methodology including looking at the system in place for the management 
of  TEP/DNARs,  as  my  concern  is  that with  inaccurate  information  and  the 
inability to check that information that potentially decisions could be made 
that perhaps would not be made leading to allowing somebody to die that 
was based on inaccurate information.  

CQC do not always routinely check all TEP/DNAR records as part of an inspection. 
This will depend on the service; the type of inspection and what concerns have 
been raised from the public or other stakeholders. 

All providers must comply with the regulations as set out in The Health and Social 
Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014.  The regulations 
that would be considered with any reviews around DNAR/TEP forms would be: 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Regulation 9 (Person-Centred Care) 
•  Regulation 11 (Need for Consent) 
•  Regulation 12 (Safe Care and Treatment)  
•  Regulation  13  Safeguarding  service  users  from  abuse  and  improper 

treatment  

•  Regulation 17 (Good Governance)  

For all health and social care providers, CQC would look at the regulations outlined 
above and determine whether there is evidence of compliance under each of the 
Key Lines of Enquiry (KLOE) relative to the provider type. This would include care 
planning, end of life care and treatment, consent processes and who was involved 
in the decisions around care planning and treatment. 

A provider’s compliance with the regulations will be assessed at inspection. As part 
of a CQC comprehensive inspection the practice will be inspected against five key 
questions,  whether  a  service  is  safe,  effective,  caring,  responsive  and  well  led. 
Each of the five key questions are broken down into a further set of questions, the 
key lines of enquiry (KLOEs). When CQC inspects, these are used to help CQC 
decide what the inspection needs to focus on. For example, the inspection team 
may look at care planning, end of life care and treatment, consent processes and 
who was involved in the decisions around care planning and treatment. As part of 
the consideration as to whether a service is safe, effective, caring, responsive or 
well  led,  CQC  will  consider  how  governance  systems,  processes  and  practices 
keep  people  safe,  how  these  are  monitored  and  improved  and  whether  staff 
receive effective training in safety systems, processes and practices. 

In  the  event  of  a  specific  DNAR/TEP  concern  being  raised  by  a  whistle-blower, 
CQC inspection teams may conduct investigations to determine whether providers 
undertake  appropriate  DNAR/TEP  assessments,  how  accurate  and  complete  is 
the information is and how DNAR/TEP forms are reviewed. Checks are made to 
ensure providers processes and systems align with the Resuscitation Council’s UK 
Publication: ‘Decisions relating to cardiopulmonary resuscitation’ and TEP forms 
in line with ReSpect guidance seen on the Resuscitation Councils website.  

In October 2020, the Department of Health and Social Care asked CQC to review 
the  use  of   Do  Not  Attempt  Cardiopulmonary  Resuscitation  (DNACPR) 
decisions during  the  COVID-19  pandemic. This  has  been  an  area  of  shared 
concern about  the blanket  application  of  DNACPR decisions.  Our interim  report 
was  published  in  November  2020.    A  national  report  of  our  findings  and 
recommendations will be published by March 2021. This report will set out all the 
themes  and  trends  we  have  found,  outlining  any  known  changes  to  the  use  of 
DNACPR in response to the pandemic and describing good practice for the future. 

We are currently now in a period of consultation about our next steps of regulation. 
During this time, we will continually keep our scope of regulation under review and 

2 

 
 
 
 
 
 
 
 
 
 
 update our regulatory approaches frequently. This may include strengthening how 
we  regulate  care  and  treatment  around  end  of  life  and  specifically  DNAR/TEP 
forms in the future.  

We continue to respond to risk via routine monitoring and inspection during this 
consultation period, including concerns and issues raised in this report.  

CQC Regulatory Action: 

CQC undertook an inspection in June 2016 at the GP practice where Vhari Ingall 
was registered as a patient. This inspection was undertaken prior to the death of 
Ms  Ingall.  There  were  no  areas  of  concern  in  relation  to  the  relevant  practice 
policies,  staff  understanding,  training  and  systems  to  support  patients  with  their 
care, treatment or planning for their end of life. 

We undertook an annual regulatory review at the same practice in July 2019 and 
our assessment found no areas of concern in relation to the care and treatment of 
patients at this time. 

In  terms  of  Mary Grace  Johnson,  your concerns  relate  to  the  DNAR/TEP  forms 
being used for people who choose to take their own life. We have reviewed the 
information  and  believe  that  there  were  no  concerns  about  Ms  Johnson’s  GP 
practice. Patford House Surgery was inspected in November 2018 and there were 
also  no  concerns  relevant  practice  policies,  staff  understanding,  training  and 
systems to support patients with their care, treatment or planning for their end of 
life. 

Where CQC identifies that regulations are not being met, we use our enforcement 
powers to require improvements to be made. We continue to do this and will share 
key learning and practice points from the inquest into the death of Vhari Ignall and 
Mary Grace Johnson with inspectors. 

We  hope  that  this  response  addresses  your  concerns.  Should  you  require  any 
further information then please do not hesitate to get in touch.  

Yours sincerely 

Head of Inspection- PMS South East and South West. 

3

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

     12 April 2021 

Mr David Ridley 
HM Senior Coroner, Wiltshire and Swindon 
HM Coroner's Court 
26 Endless Street 
Salisbury SP1 1DP 

Dear Mr Ridley, 

Thank you for your correspondence of 19 January 2021 to Matt Hancock about the death 
of Vhari Ingall. I am responding as the Minister responsible for patient safety and I am 
grateful for the additional time in which to do so 

Firstly, I would like to take this opportunity to offer my sincere condolences to the families 
of Vhari Ingall and also Mary Johnson, who you also refer to in the Report. 

I have noted carefully your concerns about the interpretation of the use of Treatment 
Escalation Plan/Do Not Attempt Cardiopulmonary Resuscitation (TEP/DNACPR) forms 
and the difficult position paramedics may face in intervening appropriately in providing 
emergency care.  

In preparing this response, my officials have made enquiries with NHS England and NHS 
Improvement (NHSE/I) and the Care Quality Commission (CQC).  Responses from CQC 
and the Association of Ambulance Chief Executives (AACE), to an earlier Regulation 28 
notice relating to Vhari Ingall’s death, have also been brought to the department’s 
attention. 

Advance person-centred care planning enables individuals to make informed decisions 
about their future care treatment and support.  As part of this planning, DNACPR decisions 
can allow focus on the wishes of the individual in cases where cardiopulmonary 
resuscitation (CPR) may be needed. However, unless it meets the strict criteria for an 
advance decision to refuse treatment, a DNACPR decision itself is not legally binding. The 
form should be regarded as an advance clinical assessment and decision, recorded to 
guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest 
or death.  The final decision regarding whether or not attempting CPR is clinically 
appropriate, rests with the healthcare professionals responsible for the patient’s immediate 
care at that time. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A DNACPR decision does not override clinical judgement in the unlikely event of a 
reversible cause of the person’s respiratory or cardiac arrest that does not match the 
circumstances envisaged when that decision was made and recorded. 

In most hospitals the average survival to discharge rate for CPR has been given as 15-
20% of patients. Where CPR is attempted out of hospital, the average survival rate is 
given as between 5-10%. However, the probability of success depends on many factors.  

There is a range of national guidance on the application of DNACPR forms to assist 
healthcare professionals.   

The Department has commended to NHS Trusts the expert advice provided in Decisions 
relating to cardiopulmonary resuscitation1 (2016).  This is joint guidance on decisions 
relating to CPR from the British Medical Association, Resuscitation Council UK and Royal 
College of Nursing.  The guidance has provided a sound framework to support these 
decisions and for communication with the patient or those close to the patient. 

The guidance provides general principles that allow local CPR policies to be tailored to 
local circumstances.  Healthcare professionals also have access to other guidance, 
including: 

•  Ethical guidance on care and treatment towards the end of life from the General 

Medical Council2; and  
•  The ResPECT process3 

The joint guidance is clear that a DNACPR decision applies only to CPR and that “all other 
appropriate treatment and care for that person should continue”. 

On your point of having a central database for DNACPR forms, a DNACPR decision is to 
provide immediate guidance to attending professionals. Recorded decisions about CPR 
should be up-to-date and accompany a patient when they move from one setting to 
another. Record sharing capability relating to DNACPR forms varies across the country 
and remains a key priority for the NHS.  Examples of where this is working well include 
those that have adopted the Recommended Summary Plan for Emergency Care and 
Treatment4 (ResPECT) process and areas using frameworks such as Coordinate My 
Care.  

Guidance also exists on the review of CPR forms. The ethical guidance on care and 
treatment towards the end of life from the General Medical Council states clear 
arrangements should be in place to review DNACPR decisions with patients where a 
condition may have improved.  Practitioners are advised to seek a second opinion or 
advice from an experienced colleague, where necessary.  

At the time a DNACPR decision is made, patients should be informed when the decision 
will be reviewed, and the review date recorded on the DNACPR form. It is recommended 
that a DNACPR form is reviewed each time a patient’s situation changes. The frequency of 
review should be determined by the healthcare professional responsible for their care and 
influenced by the clinical circumstances of the patient.  The GMC guidance further states 

1 Decisions relating to CPR (cardiopulmonary resuscitation) (bma.org.uk) 
2 Cardiopulmonary resuscitation CPR - GMC (gmc-uk.org) 
3 ReSPECT | Resuscitation Council UK 
4 https://www.resus.org.uk/respect/respect-healthcare-professionals  

 
 
 
 
 that “revision of decisions about CPR should be as responsive to changes in a patient’s 
clinical condition and physiological observations as review and revision of any other aspect 
of their treatment”. 

In light of concerns around DNACPR notices used during the pandemic, the Department 
commissioned the Care Quality Commission to review the use of DNACPRs and provide a 
series of recommendations to ensure inappropriate notices are not placed on patient’s 
records.  The final report was published on 18 March 2021. We are committed to driving 
forward implementation of the recommendations within the report. 

I hope this information is helpful and explains the actions being taken to address the 
matters of concern.  Thank you for bringing these matters to my attention. 

NADINE DORRIES MP 
MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH

r~1:b1 

South Western 
Ambulance Service 
NHS Foundation Trust 

Trust Headquarters 
Abbey Court 
Eagle Way 
Exeter 
EX27HY

Tel: 01392 261500 
Fax:  01392 261510 
Website: www.swast.nhs.uk 

Our ref:  WW60.as 

9 October 2020 

Private & Confidential 
HM Coroner David Ridley 
Senior Coroner for Wiltshire &  Swindon 

By email only: WSCoronersOffice@wiltshire.gov.uk 

Dear Mr Ridley 

Prevention for Future Death report touching on the deaths of Mrs Mary Johnson and 
Ms Vhari lngall. 

I write in connection with your inquiries touching on the deaths of Mrs Mary Johnson and 
Ms Vhari  lngall, and in response to the Prevention for Future Deaths Report issued to South 
Western Ambulance Service Foundation Trust on 1s~ou will be aware that the report 
was marked for the attention of my predecessor-M r~ please note that I have since 
assumed the role of Chief Executive Officer and accordingly have sought to address the concerns 
you raise below. 

I was extremely saddened to hear of both Mrs Johnson and Ms lngall's deaths and understand that 
the circumstances of these deaths would have been extremely difficult for both families. I would 
therefore like to take this opportunity to offer my sincere condolences to the families of both 
Mrs Johnson and Ms lngall and to reassure you that both cases have been taken extremely 
seriously, with a significant amount of work undertaken to ensure any learning identified is 
embedded within the organisation. 

Whilst I am aware that the events leading to their respective deaths were somewhat different, 
HM Coroner has, within the report drawn parallels between the two incidents, identifying two chief 
concerns: 

•  Do Not Resuscitate (DNAR) Forms only apply in circumstances where patients will have a 
'natural' death and would therefore not be applicable in circumstances where a patient has 
self-harmed as this could in  no way be considered a  'natural' death and 

•  The requirement for paramedics to make decisions regarding the resuscitation of patients 
who have self-harmed and who are in  possession of documents that purport to support 
their actions. 

In order to address the concerns, I would advise that both patient deaths have been investigated 
separately by way of Review, Learn and Improve investigations (formerly known as Serious 
Incident investigations) and comprehensive reports compiled,  both of which will  be shared with the 
respective families and will be provided to HM Coroner separately. 

Although distinct from one another, the investigations have run concurrently and have sought to 
address a myriad of complex issues, ranging from: 

•  Capacity assessment in  intoxicated patients, how this is assessed and the factors to be 

considered; 

 •  Consent to treatment in circumstances where a patient has refused treatment and is 

assessed as having capacity; 

•  Best-interest decision making and the weight to be apportioned to each factor considered; 
•  The validity and applicability of documentation including DNARs and advanced decision 

documentation in circumstances where a patient has self-harmed; 
•  The extent to which paramedics should exercise professional curiosity; 
•  Availability and accessibility of available guidance for paramedic crews; 
•  The extent to which paramedics are able to access expert mental health and senior clinical 

support externally. 

One of the similarities between the two cases is that Mrs Johnson and  Ms lngall both had DNAR 
forms in addition to other documentation including advance decisions or a TEP (Treatment 
Escalation Plan) and notes expressing a wish to end their lives. 

A DNAR form is not a legally binding  document and as HM Coroner has identified, would not be 
applicable in circumstances where a patient has self-harmed, as this would not achieve a naturally 
occurring death.  Conversely, an advanced decision (or ADRT (advanced decision to refuse 
treatment)) may be applicable if specific to the set of circumstances, is valid and there is no reason 
to doubt the patient's capacity at the time of writing. 

In the case of Mrs Johnson, the investigation revealed that the paramedic who attended her was 
aware that the  DNAR documentation was not applicable but was nevertheless keen to ensure 
Mrs Johnson's wishes were factored into the decision making, as expressed by her actions in 
taking an apparent overdose and within the documentation provided, which included a note 
detailing her expressed wish to end her life. The paramedic sought advice from the Senior Clinical 
Advisor on-call (ambulance senior clinician) on this point and having consulted with Mrs Johnson's 
family at length, made a 'best interests' decision to leave Mrs Johnson with her family- that is a 
decision that incorporates all known variables with a view to making what was perceived to be the 
right and best decision for the patient. 

In Ms  lngall's case, the investigation showed that the paramedic crew spent a vast amount of time 
with her on scene,  endeavouring to persuade her to go to hospital to receive treatment following an 
overdose of medication. Similarly, Ms lngall had both a DNAR and a TEP in her possession, 
neither of which applied. By contrast, although it was acknowledged by the crew that Ms lngall was 
intoxicated, they did not consider the level of impairment to be so great that it impacted on her 
capacity to make decisions, however unwise they might have been. The crew recall repeatedly 
assessing  Ms lngall 's capacity throughout their time with her and  report that she was able to 
converse with them freely and demonstrated a clear understanding of the consequences of her 
actions, explaining that she was aware that she would die without treatment. 

The crew report that Ms lngall had capacity up until she rapidly deteriorated and went into 
respiratory arrest and  made considerable attempts to seek external support via mental health and 
out of hours' services.  Ultimately,  although the crew mistakenly considered the documentation to 
be applicable,  their decision to allow Ms lngall to die was predominantly based on their repeated 
assessment of her having the capacity to make her own decisions and the demonstration of her 
understanding of the consequences. They therefore did not consider it appropriate or in the 
patient's best interests to treat and resuscitate. 

Given the complexity of both cases and the plethora of issues explored,  the investigating team 
reviewed the guidance available to crews with a view to establishing both the accessibility and 
level of clarity provided for the management of patients who have self-harmed and refuse 

Chalrman: -
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• •• r1  amp! ~aymt nl Code  m 

-

 treatment. They found that whilst there is a wealth of national and internal guidance available, in 
situations such as those described above, where paramedics are faced with a multitude of issues, 
the relevant guidance is often contained within multiple sources, necessitating a need to read 
various texts in conjunction with one another to enable them to formulate a plan. 

Therefore,  in addition to a clear requirement to reinforce education around the legality and 
applicability of documentation such as DNARs and ADRTs, in circumstances where a timely 
response is imperative, proactive steps have been taken by SWASFT to ensure a greater 
understanding of these issues and to embed the learning taken from these incidents with a view to 
improving the quality of the service provided to our patients and their families. 

In terms of the action taken by SWASFT, it was recognised that immediate action was required to 
ensure staff understood their legal obligations and could distinguish between the varying 
documents they might encounter, including DNARs, Advance decisions and a Lasting Power of 
Attorney (LPAs). Accordingly, as an interim measure, a Clinical Notice was issued to all staff on 
22nd May 2020, a copy of which is enclosed for your ease of reference. 

It was, however, acknowledged that a more robust review of guidance was required, with a view to 
developing a more focused guideline identifying the key steps to be considered by crews, in 
addition to some detailed explanatory text identifying the legislation that underpins it. There ensued 
a process of collating the relevant information from various sources and  incorporating it all into one 
accessible and easy to comprehend document. A guideline entitled 'Mental Health and capacity 
considerations in patients who present as having self-harmed or attempted suicide' has now been 
developed by the team, incorporating references to JRCALC (Joint Royal  Colleges Ambulance 
Liaison Committee),  NICE and internal SWASFT guidance. Given the complexity of the task, 
specialist legal input was sought in addition to the clinical expertise of a mental health expert who 
has provided some valuable insight into the management of patients who have self-harmed. One 
area HM Coroner may wish to explore further relates to the applicability of ADRTs in 
circumstances where the patient has self-harmed and refuses treatment. It is understood that 
provided the ADRT is valid,  clearly provides for the specific set of circumstances in which the 
patient presents, and there is no reason to suspect the patient did not have capacity at the time of 
writing, the ADRT would be legally binding. The concern here is in relation to the capacity of the 
patient at the time the document was drafted, given this may not have been formally assessed and 
so may be questionable if in a state of suicidal crisis for example. Although the guideline attempts 
to address this matter, it is arguable that the law may need to be clarified around this point. 

The Trust will implement the new guideline on  14th October and will notify staff of this together with 
a briefing of the subject matter via the Chief Executive's bulletin the same day.  Members of the 
Quality and Clinical Care directorate will then work alongside the Learning and  Development team 
to design training materials to be delivered to staff as part of the 2021 /22 staff training package. 
Given the complexity of the subject matter, it will be important that the content is carefully 
considered and planned so as to ensure effective delivery to the workforce. Completion of the 
training is mandatory with the obvious exceptions made for those on maternity and sick leave.  In 
previous years the Trust has routinely achieved 90-95% of the workforce trained with a firm plan to 
ensure that 100% of the workforce has received their education by the end  of quarter 1 the 
following year. A copy of the guideline has been enclosed for information and the Trust will also 
share the new guidance with the Association of Ambulance Chief Executives and CQC in due 
course. 

In terms of other actions taken, although the formulation of a new guideline was a key 
recommendation made for both RLI  investigations, other actions included working closely with local 
mental health trusts and out of hours' services to strengthen communication links and the support 
provided to paramedic crews managing mental health patients.  In addition, although it is clear from 

 the investigations undertaken that the crew members did their very best for both patients, individual 
learning was identified and  I understand all those involved have thoroughly reflected on the 
incidents and engaged extremely well in the investigation  process. 

The Trust has also recognised the need to recruit a substantive Senior Mental Health Practitioner 
to provide ongoing advice and support to staff and to develop services sensitive to the needs of 
people with mental health issues or a learning disability. This role will provide strategic leadership 
ensuring mental health remains a key priority for the organisation. They will work with stakeholders 
to develop pathways of care and services for patients as well develop guidance and training for 
staff. One key work stream will  be to discuss with commissioners the potential recruitment of 
mental health practitioners within the ambulance clinical hubs to provide immediate advice to 
crews. 

In  conclusion,  I hope both the families of Mrs Johnson and Ms lngall, and HM Coroner will be 
assured by the decisive steps taken by the Trust to address the concerns raised and furthermore 
by the considerable amount of work undertaken to implement improvements to the service the 
Trust provides to our patients and their families. 

Yours sincerely 

Encs 

Chalrman: -
Chtef Execut ve:

Care Quality

Commission
Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
Mr. David Ridley NEW ae
HM Senior Coroner .
Wiltshire & Swindon Coroner’s Office one Ae ei
26 Endless Street
Salisbury www.cqc.org.uk
Wiltshire
SP1 1DP
21 July 2020

Care Quality Commission
Our Reference: MRR1-8774360992

Dear Mr. Ridley,

Regulation 28 report to prevent future deaths following the cases of Mary Grace
Johnson and Vhari Ingall

Following the commencement of your investigation into the deaths of Mrs. Johnson and Ms.
Ingall, the Care Quality Commission (the ‘CQC’) received a copy of the Regulation 28 report
because you felt that the commission has the power to take action.

The CQC monitor, inspect and regulate services to make sure they meet fundamental
standards of quality and safety. CQC sets out what good and outstanding care looks like and
work to make sure services meet fundamental standards below which care must never fall.

Background

South Western Ambulance Service Foundation Trust (SWASFT) is registered with the CQC
to provide the regulated activities of:

e Diagnostic and Screening Procedures

e Surgical Procedures

e Transport Services, triage and medical advice provided remotely

e Treatment of Disease, Disorder or Injury

The trust provides these services from a range of bases in the Southwest of England with its
headquarters based in Exeter. The service provided by SWASFT covers a geographical area
of one fifth of England’s land mass.

The most recent inspection report for SWASFT was published in September 2018, where the
organisation was rated “Good” overall.

The CQC became aware of the deaths of Mrs. Johnson and Ms. Ingall on 22 April 2020 upon
receipt of the first regulation 28 report. At this time, SWASFT were contacted by the CQC to
ask for the investigation reports into the deaths of the two patients. SWASFT began this
investigation upon the receipt of the Regulation 28 report, and so at this time were able to
send only the 72-hour investigation reports. Subsequent to the receipt of the amended
Regulation 28 report, where the CQC were named as responders, further information was
requested from SWASFT to enable a closer analysis both of the patients identified, but also

the processes and guidelines that supported front line staff in the treatment of all patients in
similar circumstances.

Matters of Concern:

(1) Frontline workers are taking decisions regarding non-resuscitation of
individuals with a “Do Not Resuscitate” (DNR) order in place, where it seems
apparent that the individual has — or has attempted to — take his or her own
life. A DNR document applies to allow specifically a natural death.

Immediate Concerns

Upon receipt of the regulation 28 report from the coroner and subsequent review
processes, SWASFT were asked to provide assurance that actions had been taken
to mitigate the immediate risk of a similar occurrence. The CQC were provided with
this in the required timescale, along with information about how the receipt and
understanding of this information was governed. This provided the CQC with a level
of assurance that with immediate affect, the risk of a similar occurrence is mitigated
as far as is practicable.

Ongoing Management of risk

In addition to information about the management of immediate risk, the CQC asked
SWASFT to review all cases of apparent suicide attended by their crews in the
preceding 18 months where resuscitation had not been attempted. This review was
conducted using a comprehensive review of systems used to capture information
about patients and the treatment received. This demonstrated that in such cases, the
decision not to resuscitate was legitimate in that these patients were past the point
that resuscitation could have saved their lives — and were in accordance with the
guidance provided by the Joint Royal Colleges Ambulance Liaison Committee
(JRCALC).

The CQC asked SWASFT for information that demonstrated an ongoing
management plan of the situation so that it could be assured of the sustainability of
such mitigations as described above. Information included within a letter sent to us
on 10" June 2020 provided assurance of a comprehensive plan surrounding the
development of a clearer process and policy for staff to follow, and training to sit
alongside this subject. SWASFT stated that the plan would be for this to have been
completed by all staff by March 20271. It is fair to say that we have confidence in their
ability to deliver the action plan as described, based on our knowledge and
experience of the organisation. In putting together this plan, it is our understanding
that SWASFT have worked with legal support to ensure that the information included
in the new policy is not only clear and easier to access but is also legally accurate.

With regards to the plans as outlined above, review of the achievement of this will
form part of the CQC’s ongoing engagement with SWASFT as well as being followed
up directly with front-line staff and leaders at the next inspection. SWASFT were
scheduled to have an inspection during the spring of 2020. However, due to the
coronavirus pandemic, all routine inspections were cancelled. At the time of writing, it
is not yet known when these will resume but it is not envisaged to be imminent. That
being said, should a risk present that requires a closer examination through the use
of an inspection, then one will be carried out. SWASFT’s cooperation and readiness
to mobilise a solution to the concerns outlined in the regulation 28 report does not

suggest a need to inspect at this time. However, should further information alter that
viewpoint when the investigations are completed, the situation and decision to
inspect will be reassessed.

(2) The belief of the coroner, that this may be a wider issue, nationally and not
limited to the South Western Ambulance Service Foundation Trust (SWASFT)

Information surrounding the cases of these two patients, and the subsequent actions
taken and information gained by CQC, has been shared with the national ambulance
group that sits within the CQC. This means that the findings surrounding the deaths
of these patients can be used to enhance engagement with, and ongoing inspections
of, ambulance trusts across the country.

As part of our inspection methodology, we routinely look at the training in, and
presence and understanding of processes and policies surrounding the mental
capacity act and best interest decisions. This is ordinarily a more generic look at such
subjects, and so the addition of this focus on patients who have apparently attempted
to take their own lives will be promoted within the CQC by the ambulance group.

Having reviewed the inspection reports of a number of ambulance trusts across the
country, there is no evidence that as part of those inspections the CQC has
specifically asked about the affect of apparent suicide in the presence of an DNR
document. Through the channels of communication open to the ambulance group
this question can be promoted to colleagues carrying out inspections of these trusts
in the future.

Hopefully, this letter provides you with sufficient information about the concerns
raised in the regulation 28 report surrounding the deaths of Mrs. Johnson and Ms.
Ingall, together with our ongoing regulatory approach to the matter.

Should you require any further information, please contact (inspection

Manager) by phone on 03000 MM or via e mail at §Ocac.org.uk

Yours Sincerely

Head of Hospital Inspection