Martin Sullivan

FAO: Andrew Bridgman  
HM Coroner  
Manchester South  
1 
Stockport  
SK1 3AG  

 Mount Tabor Street  

Dear Mr Bridgman  

22 nd  April 2021  

Re:    Regulation 28 Report into the death of Martin Sullivan  

We are writing in response to your Regulation 28 letter dated 2 March 2021 in relation to the death of  
Martin Keith Sullivan. We note the areas of concern that you have raised and address each of them below.  
In preparing this response we have liaised with NWAS to provide additional information and context to the  
matters of concern. At this time, as Commissioners, we also wish to formally take the opportunity to  
express our deepest sympathies to Martin’s family in addressing the concerns you have raised.   

1 . and 2. The MPDS Algorithm and Rule 6  

The choice of which clinical decision support tool to operate in the 999 environment lies with NWAS as the  
ambulance service provider. MPDS is an internationally developed and accredited tool provided by the  
International Academies of Emergency Dispatch (IAED) and is used by several UK ambulance services. The  
outcomes reached after MPDS assessment are aligned to the ambulance response categories. These are  
nationally determined and not set by NWAS or commissioners.  

The identification of ineffective breathing, which would receive a Category 1 response, is an ongoing  
challenge to all ambulance services. Historically call takers were required to remember phrases or words  
given by the caller that indicated the patient was suffering from ineffective breathing.   

NWAS established an internal task and finish group in 2019 to understand the issues in more detail and to  
feed into the national review process. On reviewing the outcomes of this task and finish group NWAS  
decided that further work was still required to further improve the identification of ineffective breathing  
and there was wider recognition of the issue. This has been taken forward nationally as this is a theme  
raised by all Ambulance Trusts utilising MPDS. NWAS, alongside other ambulance trusts, are part of a  
national working group to agree revisions to MPDS standards, including the identification and recognition  
of the importance of ineffective breathing.  

A series of actions were taken in January 2020 to further improve the responsiveness to calls involving  
ineffective breathing and are summarised as follows: -  

•   

 training of all their call takers, along with issuing operational educational bulletins and  

1:1 
introducing an electronic ‘pop up’ to aid call takers in identifying ineffective breathing  
•    Staff bulletins issued to reinforce where and how ineffective breathing should be identified  

 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
   
  
  
  
  
   
  
 Further and ongoing thematic analysis and reporting  

•  A review and reissuing of training packages  
• 
•  NWAS developed a simulation-based online training platform, which is waiting to go live, coupled 
within a focused communications campaign within each of the NWAS Emergency Operations 
Centres (EOCs)  

Progress against these actions is regularly reviewed at each monthly meeting of the commissioner-led 
Regional Clinical Quality Assurance Committee (RCQAC) to ensure that actions continue to be taken, and to 
support NWAS in national discussions on the ineffective breathing MPDS algorithm and working closely 
with the IAED to establish best practice for the identification of ineffective breathing and developing 
processes that will further reduce future risk.  

The current position is that as of January 2021 NWAS perform similarly to other ambulance services in this 
regard and are not a national outlier in recognition of ineffective breathing.  

3. Service Performance and Contracting  

In terms of addressing your concerns regarding the performance of the service we felt it would be helpful 
to compare NWAS performance against the other ambulance trusts for the time in question. In the week in 
which the incident occurred no ambulance service nationally achieved the Category 1 mean response 
standard, and only 2 of the 11 trusts achieved the Category 2 mean response standard. Included in the 
appendix is a visual representation based on national data that shows this position.   

All ambulance trusts principally achieve the Category 1 90th percentile standard, but again only 2 
ambulance trusts achieved the Category 2 90th percentile standard in the week in question. This highlights 
the significant operational pressures all ambulance services were facing at the time and the challenges 
adapting to the new service models needed for the Ambulance Response Programme (ARP) approach 
nationally adopted in August 2017 (Appendix 1).  

In terms of addressing your concerns regarding the funding that is placed to allow NWAS to deliver the 
service, we have summarised the contacting process as follows. On an annual basis, in line with the 
requirements of the annually published NHSE/I Planning Guidance, discussion meetings are held between 
commissioners and NWAS. Their purpose is to negotiate and agree the contract both in terms of cost, 
volumes of activity based on previous funding levels, achievement of performance standards and agreed 
internal transformation plans in line with the national Planning Guidance requirements.  

The starting point for this is the historical cost of the service, any anticipated increases in overall demand 
for the service, how the demand is balanced across the acuity of patients and how NWAS respond to the 
demand managing incidents appropriately. This covers increasing the number of options for patients who 
would elicit a Hear and Treat and/or See and Treat response to reduce avoidable conveyance. These and 
other initiatives are designed to ensure that the patient is directed first time to the most clinically 
appropriate service (only in the cases where a category 1 or 2 response is not clinically indicated). These 
initiatives are designed to support improvement in ambulance response times and release increased 
capacity for those patients who do require a category 1 or 2 response and conveyance to hospital.  Having 
agreed the contract, it is then a matter for the trust to determine, operationally, how it will respond to 
demand and deliver the national standards expected of it. Over the course of each contract year 
commissioners meet regularly with the trust to monitor levels of demand, performance being achieved and 
patient safety, and there is a well-defined governance structure in place to enable this to happen.  

The investment over recent years has been in response to changes in demand and the national Ambulance 
Response Programme (ARP) standards that were introduced in August 2017. This replaced the previous 
targets with a fairer system whereby ambulance trusts would be measured on both their mean and their 
90th percentile performance for each category of patient. Commissioners have invested significantly in the 
ambulance service since the introduction of the ARP standards.   

  
  
  
  
  
  
  
  
 The contract is based on achievement of the national ARP Targets at a North West level. This is in line with 
national policy and remains the current position. We have set out below a summary of the investment 
made by commissioners between 2016/17 to March 2019/20. This is summarised in table 1 below.  

Table 1 – Commissioner investment agreed with NWAS  

Total NWAS Funding Available  

£  

Year on Year Growth   Growth since 2016/17  

2016/17  

2017/18  

2018/19  

2019/20  

  222,910,434   

  248,735,780   

11.6%  

  261,393,154   

  283,349,758   

5.1%  

8.4%  

27.1%  

Note: The majority of the funding available to NWAS is for use by them in delivering front line services. A small 
proportion of the overall funding is for specific use including funding such as Hazardous Area Response Teams (HART) 
and targeted support over the winter periods.  

At the point of contract agreement, it is then for NWAS to implement an approach that will deliver the 
outcomes agreed, i.e. ARP standards. Commissioners do not specifically determine how many ambulances 
they have, where these are distributed, what shift times they operate and so on. This level of operational 
detail is down to internal NWAS planning and service delivery.  

The specific point raised in your letter of NWAS seeking additional investment in November 2019 and being 
utilised from February 2020 is not recognised by commissioners as an external funding issue. As stated 
above it remains for NWAS to determine in year any shift in allocations of funding flexibly within and across 
the Trust to maintain patient safety and achieve the national performance standards, performance, and 
patient safety. Therefore, we are unable to comment further on the point made as this was not a request 
made by NWAS to commissioners and our understanding is that this would be an internal operational 
matter for NWAS.   

We monitor performance by sector, sub-regional and on an overall regional trust performance daily. In 
terms of the actual deployment of resources this remains as described a matter for NWAS to operationally 
manage. We have asked NWAS to provide additional information on the activity on the day in relation to 
resources deployed at trust sub-regional and sector level at the time of this tragic incident. On the day of 
the incident at 06:22 between the first and second call NWAS had 162 incidents awaiting allocation – a high 
number of which were C2. Of the 162 waiting incidents, 82 were in GM.  

Planned resources are determined by NWAS and based on predicted activity for the particular day. Of the 6 
ambulances on duty in the Oldham sector at 06:16, when the call for this patient was received, 1 was 
unavailable in line with the Meal & Rest Break policy and finished shift at 06:30, and the remaining 
resources were already committed to incidents. The 1 unavailable resource finished shift at 06:30 and after 
the day shift commenced, was allocated to a longer waiting category 2 incident. A further 2 resources 
cleared during the call cycle but were unavailable in line with Meal & Rest Break policy. Both of these 
resources finished shift at 07:00.   

The availability of resources to respond to the incident in question and any impact of the changing daily 
profile is a matter for NWAS. However, the level of planned responding resources will vary due to the time 
of day in relation to predicated levels of activity and the level of demand at different times of the day 
(Appendix 2).  

As commissioners we are responsible for holding NWAS to account for the achievement of the ARP 
standards. In the monthly contracting meetings, we highlight any issues of performance and strive to work 

  
  
   
   
   
   
  
  
  
  
  
  
  
 with the trust to improve their performance, recognising any challenges and seek to agree remedial action 
plans within the contract terms and conditions.   

Following extreme pressure on the service in early November 2020 NWAS reviewed the effectiveness and 
appropriateness of their Demand Management Plan (DMP) in place at the time and the triggers and actions 
aligned to them.   
The DMP was subsequently replaced with a new Patient Safety Plan (PSP) on 26th November 2020. The aim 
of the PSP is to enable NWAS to respond earlier in terms of escalation in a timely and appropriate manner 
to increased service pressure, enabling an NWAS wide response as soon as identified triggers are met.   

The trigger thresholds from the DMP in many areas have been reduced to assist earlier implementation of 
actions to reduce the number of calls waiting and improve service responsiveness. The PSP is more 
interactive with the local health care economy as well as internally across NWAS, including NHS 111 and 
Patient Transport Service.  

In conclusion we acknowledge the findings made at the Inquest that there were issues with the 
prioritisation of the call and that on the day NWAS were unable to allocate resources to ensure Martin 
received care within the ARP target time. In our response we have sought to provide additional details and 
information to give assurance that there is and has been active, detailed work undertaken to address a 
nationally recognised challenge in relation to the identification of patients with ineffective breathing. This 
work continues and receives regular oversight through our clinical governance and quality interactions with 
the trust. In addition, we have sought to provide more detailed information with regards to the funding of 
NWAS and the contractual relationship between commissioners and the trust.   

Yours sincerely  

Director of Ambulance Commissioning (North West)  
Hosted by NHS Blackpool CCG  

  
  
  
  
  
  
  
  
  
  
  
 Appendix 1  

Visual representations of performance achieved nationally by ambulance trusts in the week in which the incident occurred.  

  
  
  
  
  
  
  
  
   
     
 
 Appendix 2  

Hour  
of  
Day  

NWAS & GM Staffing levels for Sunday 24th November 2019  

0600  

0700  

0800  

0900  

1000  

1100  

1200  

1300  

1400  

1500  

1600  

1700  

1800  

TOTAL  

GM Rostered  

59.8   

59.0   

78.0   

84.8    100.5    105.5    116.0    121.0    122.5   

123.5   

120.5    120.3    124.7    1,336.1   

GM Planned  

58.3   

60.4   

77.0   

83.3   

97.5    102.5    111.0    116.5    118.0   

118.8   

115.3    115.3    116.7    1,290.4   

GM VAS / PAS  

1.0  

1.0  

2.0  

3.0  

5.0  

7.0  

8.0  

8.0  

8.0  

8.0  

8.0  

8.0  

8.0  

75.0   

Difference  

-0.5   

2.4   

1.0   

1.5   

2.0   

4.0   

3.0   

3.5   

3.5   

3.2   

2.8   

3.0   

-0.0   

29.4   

Hour  
of  
Day  

0600  

0700  

0800  

0900  

1000  

1100  

1200  

1300  

1400  

1500  

1600  

1700  

1800  

TOTAL  

NWAS  
Rostered  
NWAS  
Planned  

NWAS VAS / 
PAS  

181.8    189.0    236.5    245.3    278.0    294.5    313.5    322.5    338.0   

339.0   

335.0    335.8    337.7    3,746.6   

172.6    183.5    229.4    238.3    268.5    286.0    302.0    310.4    325.5   

326.8   

322.3    323.3    319.8    3,608.2   

2.0   

1.0   

2.0   

3.0   

8.0   

13.0   

15.0   

15.0   

15.0   

15.0   

15.0   

15.0   

15.0   

134.0   

Difference  

-7.2   

-4.5   

-5.1   

-4.0   

-1.5   

4.5   

3.5   

2.9   

2.5   

2.7   

2.3   

2.5   

-2.9   

-4.4   

  
          
  
 
  
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
     
  
  
  
  
  
  
  
  
  
  
  
  
  
  
     
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
     
  
  
  
  
  
  
  
  
  
  
  
  
  
   
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 Rostered = Covering every shift for the full length of the shift. I.E. 100% staffing.  

Planned = This level is Rostered minus the following: Vacancies, abstractions (such as Annual Leave, Sickness, any  
training or stand downs), shift swaps or any other reason why a member of staff is not on their shift for that day.  

Then Plus the following:   

Relief staff to back fill abstractions (such as Annual Leave, Sickness, any Training, etc.), plus Overtime, plus Private and  
Voluntary ambulance vehicles.    
This level is the Planned level and is the best that the rostering teams as able to produce with the staff available to them. 
This is the final level that is provided to EOC in advance.  

Actual - This is the Planned level minus any last minute ("On the Day") downtime or changes, such as: Lateness, no  
vehicle available, late notice sickness, meal / rest breaks, etc.  This level is only available from the CAD systems and is not 
in this report.    

The planned data for this report has been taken from GRS using the attached SQL. The Rostered level was taken from   
the Second script. These are both long standing scripts for calculating Planned and Rostered levels. Calculating a  
historical Rostered does mean that it can be affected by any changes made by the Rostering staff.  

The information in this report is reliant on the accuracy of the information entered into GRS and is accurate to GRS as at  
09:00 14/04/2021.

Mr Andrew Bridgman,   
Assistant Coroner  
Coroner’s Court  
1 Mount Tabor Street  
Stockport  
SK1 3AG  

                                    Professor 

Medical 

                                      National 
Director  
                                                      Skipton 
House  
                                                   80 
Road  
                                                               SE1 
6LH  

London 

                                                       4th June 
2021  

Dear Mr Bridgman,   

Re: Regulation 28 Report to Prevent Future Deaths – Martin Keith Sullivan  
(24 November 2019)  

Thank you for your Regulation 28 Report dated 2 March 2021 concerning the death 
of Martin Sullivan on 24 November 2019. Firstly, I would like to express my deep 
condolences to Martin’s family.   

The Regulation 28 Report concludes Martin Sullivan’s death was a result of multiple 
organ failure.   

Following the inquest you raised concerns in your Regulation 28 Report to NHS 
England regarding the MPDS script and algorithm.  

MPDS has been in operation across the world triaging millions of 999 calls since 
1979. The International Academy Emergency Despatch continually reviews and 
updates the 36 protocols covering the full range of emergency call reasons from  
Abdominal Pain and Burns to a specific pandemic protocol. One of the fundamental 
principles of the triage tool is the identification of priority symptoms such as choking 
or breathing problems.  The MPDS algorithm, where applicable, does combine 
answers to questions to determine a higher level of acuity. Emergency Medical 

                                            NHS England and NHS Improvement  

  
  
  
 
  
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
 Despatchers (999 call handlers or EMDs) are trained to elicit the main reason for the 
emergency call using a number of different methods, set out below.  

The case entry process establishes the main reason for the emergency call and is 
referred to as chief complaint selection (this is which of the 36 protocols to choose); 
it is also designed to elicit the level of consciousness and breathing status.  This 
leads to the early identification of patients in, or at risk of, airway obstruction, life 
threatening breathing compromise, and cardiac arrest.    

The use of an open-ended question at the beginning of the call has been proven to 
elicit an appropriate response from the caller to enable appropriate categorisation.  
“Tell me exactly what’s happened?” gives the caller the opportunity to state why they 
have called. This information is combined with the responses to specific questions 
about breathing.    

The understanding of ineffective breathing and its trigger phrases is a crucial part of 
using the MPDS system, and EMDs must have a thorough understanding of what 
ineffective breathing means.  In the context of a patient with severe respiratory 
distress, on most occasions the caller will answer with some form of description of 
the breathing problem.  Research of millions of emergency calls led to the 
development of trigger phrases, or any reasonable alternatives, as descriptors for 
ineffective breathing.   The eight phrases cover a wide spectrum of life threatening 
respiratory compromise from ‘turning blue’, ‘barely breathing’ to ‘can’t breathe at all’.  
These patients are recognised as fighting for air and have ineffective breathing.  If a 
description of the patients breathing is not offered as part of “Tell me exactly what’s 
happened” it is then directly asked in case entry, is s/he breathing?”    

EMDs are trained in active listening, and it is vital they use this skill throughout the 
entirety of the call for any information that is offered; this may be additional 
information relevant to a previous answer which could indicate deterioration or 
provide the answer to a later question that does not now need to be repeated. The 
identification that the patient has asthma is of relevance to identifying ineffective 
breathing, as the threshold for asthma patients to be identified as ineffective 
breathing is lower.  Rule 6 protocol 6 sets out very clearly:   

Asthma patients are usually very experienced in managing their disease. 
When the status of these patients is reported “Can’t breathe”, “Unable to 
breathe”, or similar description this should be considered INEFFECTIVE  
BREATHING  

It is not the case that the system is relying on the information being 
offered/volunteered but rather that the questions within Protocol 6 will elicit the 
information required.  It is in response to both the open and closed questions that 
the EMD must recognise ineffective breathing in a patient with asthma.  When 
applied correctly this is a very reliable method of determining life threatening 
respiratory distress including life threatening asthma.  Any patient who is identified 
as ineffective breathing should receive a category 1 response.  Acute severe asthma 

                                            NHS England and NHS Improvement  

  
  
  
  
  
  
 is allocated a category 2 emergency response. This reflects the absolute urgency for 
patients with ineffective breathing.   

As per MPDS procedure, any patient with severe breathing problems who is at risk 
of deterioration the EMD is required to stay on the line and monitor for deterioration. 
Information gained during this period should be triaged accordingly; additional 
information such as “he can’t breathe properly” (Rule 6 for Asthma patients) should 
be upgraded to a category 1 response.  

For the reasons set out above, it is the view of NHS England and NHS Improvement 
that the algorithm, when used correctly, does identify life threatening asthma and will 
result in a Category 1 response.  

In order to ensure that the process of identifying ineffective breathing is embedded 
within all ambulance services NHS England and NHS Improvement will hold a 
learning event with all ambulance services, inviting the involvement of triage system 
providers, to share best practice and ensure ambulance services are enabled to 
utilise the triage systems safely and effectively.  

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

Yours sincerely,  

Professor 
National Medical Director    
NHS England and NHS Improvement   

                                            NHS England and NHS Improvement