Thomas Rawnsley

National Medical Director

Ms Abigail Combes Skipton House
Assistant Coroner 80 London Road
South Yorkshire (West District) London
Medico-Legal Centre SE1 6LH
Watery St

Sheffield

S3 7ES 4 June 2021

Dear Ms Combes,

Re: Regulation 28 Report to Prevent Future Deaths — Mr Thomas Rawnsley
(4 February 2015)

Thank you for your Regulation 28 Report dated 9 December 2020, concerning the
death of Mr Thomas Rawnsley on 4 February 2015. Firstly, | would like to express
my deep condolences to Mr Rawnsley’s family.

Secondly, | would like to apologise for the delay in response.

The regulation 28 report concludes Mr Rawnsley’s death was “Natural Causes” and
that Mr Rawnsley died as a result of

1a: Global hypoxic-ischaemic encephalopathy
1b: Cardio-respiratory arrest

1c: Chest infection

Il: Down’s Syndrome

Following the inquest, you raised concerns in your Regulation 28 Report to NHS
England regarding

(1) Primary care are undertaking more and more virtual consultations with patients
and the advice that is provided is inherently more risky over the phone with GPs
not being in a strong position to assess the patients understanding of the advice
that has been given in the same way as they can when the patient is sitting in
front of them in the practice. This advice is not followed up in writing and
therefore it may be misinterpreted or incorrectly passed from one care team to
another in the event of someone, like Thomas, is having his care delivered by
professional carers.

(2) There is a standard set of questions asked by the call handler on a 111 or 999
call which is not then replicated for clinicians who subsequently triage a patient.
Without a standard set of initial questions asked it is entirely possible that
clinicians will provide advice in isolation of other important matters. This could be

NHS England and NHS Improvement

as simple as current medications that the patient routinely takes or current
diagnosis the patient has which impact upon the advice to be provided. This may
lead to incomplete or worse, inappropriate advice being given to patients during a
clinical triage.

Point 3 of the Regulation 28 would be more appropriately answered by the
Yorkshire Ambulance Service.

With regard to Point 1: NHS England and NHS Improvement (NHSE/I) understands
the Coroner's concerns raised around consultations which are not undertaken in
person, and we are assured that there are both new and established procedures in
place to ensure that this is a safe practice. These are also supported by published
guidance and training, which | aim to summarise below.

Telephone consultations have been in use in general practice for many decades to
help patients access medical advice and care quickly and conveniently. Where
studies have been conducted, telephone care has been shown to be safe.
Telephone consulting is included as part of the general practice curriculum and
training to support safe and effective practice.

It is clear the use of virtual consultations with patients and the delivery of NHS
services remotely has progressed significantly and continues to evolve. The
coronavirus (COVID-19) pandemic has brought about an unprecedented
acceleration in the adoption of delivering NHS services remotely, and standard
operating procedures have been produced to ensure general practice is able to
operate safely in this context. These procedures make it clear that general practices
and Primary Care Networks should triage patients remotely (determine the right
person and timeframe for managing the problem) in advance wherever possible to
help prioritise patient care based on needs; and that clinicians should determine the
most appropriate consultation method with the patient - telephone, video, online,
face to face. This should be determined by taking into consideration the patient's
preferences, needs (including accessibility, privacy, capacity and communication
requirements), clinical circumstances and currently, local risks of COVID-19.

In determining the most appropriate consultation method, considerations regarding
patient safety, ability to make a satisfactory assessment, gain a sufficient
understanding of the problem and whether information can be provided in a way the
patient understands including assessing a patient's understanding of the advice
provided should be factors in determining the most appropriate consultation method.
Safety netting is a routine part of general practice consultations and explicitly sets
out next steps to take for the patient in the event of a deterioration in their condition.
The importance of these principles is emphasised in joint guidance between the
Royal College of General Practitioners (RCG)P and NHS E/I (link is included later in
my response).

If a particular concern did arise following a remote assessment or remote advice
being given, then a decision could be made to move to an alternative approach, for
example, face to face consultation or for remote advice to be followed up in writing or
with the patient's permission with their carer.

Based on the clinical circumstance and considerations outlined above, many
clinicians have used SMS and online messaging services that are now available in
general practice to follow up a remote consultation with a patient with links to
validated advice via NHS.UK, or attach information leaflets which patients can refer
back to. Patients are also now able to request full access to their medical record
which would enable them to refer back to previous consultations. The approach used
would be expected to be tailored to the circumstance and individual patient needs
taking into account the risk of information being “misinterpreted or incorrectly passed
from one care team to another in the event of someone, like Thomas, is having his
care delivered by professional carers”.

Professional guidance published by the General Medical Council sets out high level
principles of good practice expected of everyone when consulting and or prescribing
remotely from the patient. https:/Avww.gmce-uk.org/ethical-quidance/learning-
materials/remote-prescribing-high-level-principles

Additionally, guidance has been developed jointly between NHS E/I and the Royal
College of General Practitioners (RCGP) on Remote vs Face to Face: which to use
and when?, Principles of safe video consulting in general practice during COVID 19
and RCGP - Top 10 tips for COVID-19 telephone consultations.

All these documents underline the importance of ensuring patient safety and that an
individual's needs are paramount.

A further development since 2015 is the increased focus on improving how health
services understand and respond to the needs of patients with learning disabilities
and autism. The NHS E/l Long Term Plan highlights this as a priority and describes
work being undertaken to implement national learning disability improvement
standards for all services funded by the NHS. This includes, by 2023/24, a ‘digital
flag’ in the patient record which will ensure staff know a patient has a learning
disability or autism. The use of this ‘digital flag’ should further enable consideration
of the needs of patient with regard to virtual or remote consultation.

In light of the above we consider it would be disproportionate to routinely require the
provision of written follow up information following any and every remote consultation
in primary care but that this should be based on clinical judgement.

In respect of Point 2: Turning to the recommendation on replicating the standard set
of questions asked by 111 call handlers to clinicians subsequently involved, the
current “standard set of questions” utilised in NHS 111 services is NHS Pathways.
NHS Pathways is a series of questions, that assesses symptoms presented at the
time of the call and identifies the appropriate next level of care.

NHS Pathways triage is built around a clinical hierarchy, meaning that life-
threatening symptoms are assessed at the start of the call, triggering ambulance
responses as necessary and progressing through to less urgent symptoms that
require a less urgent clinical endpoint (or disposition).

Where a call is passed for further clinical assessment or consultation, all questions
asked along with their response are shared with the receiving clinician to inform their
subsequent assessment and decision-making.

If the case is subsequently passed to an NHS Pathways clinician, they would
validate the information that has been shared and where necessary probe further if
required to undertake a full assessment.

The process of validating the information from the initial call and probing further as
necessary provides clinicians with the basis from which to seek information on other
important matters which may impact on the advice to be provided.

Some cases will be passed to a clinician within the Clinical Assessment Service
(CAS), this will include those clinicians who formerly worked in organisations known
as ‘out of hours providers. These clinicians work within their professional
competences and training and will use the usual medical model to assess patients.
These clinicians will be subject to regular audit normally using the RCGP Urgent and
emergency Care Toolkit.

There is also increasingly better sharing of patient records between clinicians
working in different settings. Under a change in regulations (COP - Control of
Patient Information) for the coronavirus (COVID-19) pandemic to additional
information in the summary care record and/or as part of a local shared care record
GP OOH, NHS 111 and ambulance services are able to see, as a minimum, for
direct care purposes, information such as details of long-term conditions, significant
medical history, medications and allergies.

In light of this, we consider that replicating the standard set of questions asked by
111 call handlers to clinicians subsequently involved, would not improve the process
which is in place, as described above.

Thank you for bringing these important patient safety issues to my attention and
please do not hesitate to contact me should you need any further information.

Yours sincerely,

National Medical Director

Yorkshire

Ambulance Service

NHS Trust
Springhill 2
Ms A Combes Brindley Way
Assistant Coroner, South Yorkshire (West District) Wakefield 41 Business Park
Medico Legal Centre Wakefield
Watery Street WF2 0XQ

$3 7ES

Po _

Dear Ms Combes,

Inquest touching the death of Mr Thomas Rawnsley (Deceased)
Response to Regulation 28 Report to Prevent Future Deaths dated 9 December 2020

| refer to your report dated 9 December 2020 issued under paragraph 7 Schedule 5 of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, as directed to Yorkshire Ambulance Service NHS Trust (“the Trust”).

| am aware that during the inquest hearing in November 2020 in respect of Mr Rawnsley you
heard evidence on the use of Patient Information Leaflets for safety netting of patients by the
Trust's clinicians and as a result a Regulation 28 Report was issued.

The purpose of this letter is to provide you with a full response to the concern as set out in
your report, in so far as this is an issue which can be addressed by the Trust.

| set out your concern and identified action that should be taken and seek to address these
below.

Matter of concern: The information which appears on the EPR is not accurately recorded on
the patient information leaflet where pressures of time mean that paramedics are rushing to
summarise the instructions on the EPR on the patient information leaflet. This could lead to
incorrect information being provided to patients or incomplete information being provided to
patients along with the EPR not properly reflecting the information which has actually been
given to the patient.

Sor
MINDFUL VV o
as.nhs.uk Yeinoren & Vs

Action that should be taken: | would ask that your response includes consideration of regular
spot audits of a week at a time over the course of the next 12 months where paramedics are
asked to take a photograph of the patient information leaflet so that this can be accurately
compared with the EPR information in the audit process.

The Trust first introduced the Patient Information Leaflet (“PIL”) as a tool to assist patients
who were not conveyed following ambulance attendance in having written advice on
appropriate actions to take should a change in their condition occur; generic and specific
advice is prompted in the PIL. | enclose a copy of this document for your reference. |
acknowledge that currently copies of this leaflet are not kept within the Trust and the contents
are not audited, although | can say to the best of my knowledge that there has been no
evidence of any incidents, concerns or complaints raised on the content of the PILs to date.

The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28
Report and has determined an alternative process. | am aware that you invited this at the
inquest hearing and no disrespect is intended. We consider that a different approach is
required due to anticipated practical difficulties with recording of the PIL and concerns that this
method would result in an ‘on notice’ audit and results may therefore be skewed against the
true position.

We propose to undertake an audit based on a targeted request for feedback from a sample of
patients treated at home to seek their views on the nature and adequacy of information and
advice provided. This will serve two fold as the Trust will be in a position to review the
information left by the clinician, and also test the accessibility of the information to the patient
in terms of it being fully understood.

The Trust’s future intention is to ensure that contents of the PIL are fully embedded in the EPR
and, when technological developments allow, the Trust will have the facility to email this entire
record to the patient and their primary care provider.

Additionally, and as an interim phase, the Trust will undertake the following:

e Review of the content of the PIL template;

e Spot audits of care plans documented on EPRs to (1) identify if there is a record of
completion of a PIL and (2) review the quality of the advice given in the EPR;

e Launch of a communications campaign to staff as to the importance of detailed care
plans on non-conveyance;

e Re-audit following this intervention;

e Review and development of information leaflets for specific clinical conditions e.g. head
injury; and

e Development of ‘tick box’ indicators on the EPR to record information left.

| would like to assure you that the Trust takes your concern extremely seriously and, as a
learning organisation, consistently strives to improve the clinical services it delivers to patients.

Our thoughts remain with Thomas's family.

Yours sincerely

Chief Executive Officer
Yorkshire Ambulance Service NHS Trust