Adam Stone

16 February 2022 

BY EMAIL:  coroner@birmingham.gov.uk 

Miss Emma Brown 
Area Coroner for Birmingham and Solihull 

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

W:  www.aace.org.uk 

Dear Miss Brown 

REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS:  ADAM STONE 

I am writing in response to the Regulation 28 report to prevent future deaths following the inquest into 
the death of Adam Stone which you issued on 27 January 2022 to the Association of Ambulance 
Chief Executives (AACE). I am the managing director of AACE, and I have consulted with my medical 
colleagues to inform this response.  

AACE is a formally constituted private company wholly owned by the English and Welsh Ambulance 
NHS Trusts who are all full voting members. Its primary focus is the ongoing development of the UK 
ambulance sector and the improvement of patient care. It is a company owned by NHS organisations 
and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical 
practice guidelines.  

You have suggested that action is taken to prevent future deaths and requested that the AACE 
consider matters of concern in relation to the categorisation of calls to suspected ABD. Your matter of 
concern is that the continuance of a system which does not allow a category 1 response in severe 
case of ABD where restraint is taking place is putting lives at risk. 

We need to highlight that the AACE is unable to make decisions nor mandate which category of 
response 999 callers receive, this is the responsibility of NHS England who chair and administer the 
Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders 
who scrutinise evidence to support decisions about appropriate response categories for all clinical 
codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance 
trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any 
contribution to ECPAG discussion. Through this process the appropriate category of response for 
patients suspected of presenting with ABD was set by NHS England as a Category 2 response. This 
is a position AACE support - a decision arrived at following work we conducted looking specifically at 
ABD which was prompted as a result of other Coroner’s enquiries regarding which category of 
response someone presenting as possible ABD should receive.  

To help inform this decision and provide evidence, a joint police and ambulance review was 
conducted in the north of England between one ambulance service and a police force for a period of 
9 months between August 2019 to May 2020. The purpose of the joint review was to establish 
whether individual presenting features in patients who were identified by police officers on scene as 
possible ABD, might individually or in combination reliably identify an increased risk of clinical 
deterioration associated with increased mortality and to determine the most appropriate ambulance 
response time category. Police officers identified 28 potential ABD cases in the nine-month review 
period, representing 1% of the mental health or behavioural crisis 999 calls attended by the police 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 force. The review concluded that for patients who had been recognised as presenting with symptoms 
and signs of possible ABD, a Category 2 ambulance response was appropriate, if there was 
information that there were immediately life-threatening signs present, the patient should then receive 
a Category 1 ambulance response. The evidence and recommendations were accepted through the 
ECPAG process and implemented by all the UK ambulance services. 

We agree that ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a 
combination of signs and symptoms of agitation with likely physiological abnormalities, caused by one 
of a number of possible toxicological, physical, or mental health conditions. In the prehospital setting 
we are often unable to ascertain the exact cause of the presentation while providing clinical care prior 
to arrival at an emergency department. We considered whether the use of restraint alone should 
warrant an automatic Category 1 response, but this was agreed through the ECPAG process as not 
appropriate unless immediately life-threatening signs were present. An ambulance may be diverted 
away from someone having for example, a heart attack, stroke, or similar condition presenting with 
life-threatening features, if other conditions are automatically prioritised as Category 1 without similar 
clinical features.  

We would like to highlight other work we have undertaken and continue to undertake around ABD.  
We have developed and issued national clinical guidance in 2019, then updated in 2020, to UK 
ambulance clinicians. We have also supported education and presented at national conferences and 
webinars for police and ambulance staff, and we are continuing to develop further guidance around 
managing patients with extreme agitation.  

I hope that you will feel the work we have done nationally to consider the issues you have raised 
explains the current system for responding all our patients including those with suspected ABD. We 
are absolutely committed to learning from all adverse events and doing everything within our power to 
prevent them happening again in the future. 

We would also like to extend our sincere condolences to the family of Mr Stone. 

If we may be of further assistance, please do not hesitate to contact us. 

Yours sincerely 

Managing Director

Date: 21 February 2022 

Miss Emma Brown 
HM Coroner 
Coroner's Court 

Dear Madam Coroner, 

Inquest touching upon the death of Adam Marshall Elliot Stone  

I write in response to your Regulation 28 Report To Prevent Future Deaths (“PFD”) dated 27 January 
2022.  I was very sorry to learn of the death of Mr Stone and, on behalf of the College of Paramedics, 
I would like to extend my sincere condolences to his family and friends.   

The College of Paramedics is the recognised professional body for all paramedics, including those 
who operate within the ambulance sector in the UK.  We are established as a charity, with the charity’s 
objects being the “advancement of health and saving and improving of lives and the advancement of 
education,  training  and  efficiency  within  the  paramedic  profession”.  Essentially,  the  College 
represents  its  members  in  all  matters  affecting  their  clinical  practice  and  we  support  members  to 
achieve the highest standards of patient care. 

It may assist for me to clarify that the College of Paramedics is not responsible for setting standards 
for paramedics’ education, training, or practice.  That responsibility lies with the statutory regulator of 
paramedics, the Health and Care Professions Council (HCPC). However, the College of Paramedics 
will ensure that any subsequent review of its pre-registration curricula will include the latest evidence 
on Acute Behavioural Disturbance. 

The  College  of  Paramedics  is  also  not  responsible  for  determining  NHS  ambulance  response 
categories.    That  power  lies  with  NHS  England,  although  the  Association  of  Ambulance  Chief 
Executives (AACE) provide evidence and guidance to support this.  

In these circumstances, I regret that I do not believe it is within the College’s power to implement any 
particular action in response to your PFD.   

I am aware that AACE will also be writing to you in response to your PFD.  The College endorses the 
content  of  AACE’s  letter  to  you.    However,  the  College  would  always  support  an  evidence-based 
review of the current response categorisation of Acute Behavioural Disturbance in order to ensure 
that a Category 2 response remains the appropriate disposition and I will share this correspondence 
with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose that such a 
review be considered in the light of this PFD.     

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 The College of Paramedics has also been involved in collaboration with AACE on the recognition and 
treatment of Acute Behavioural Disturbance, including this topic being presented at recent Continuous 
Professional Development (CPD) events following extensive guideline development. 

Please do not hesitate to contact me if you feel that the College can be of any further assistance with 
this matter.  

Yours sincerely,  

Chief Executive

Miss Emma Brown  
HM Area Coroner for Birmingham and Solihull 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

By email: coroner@birmingham.gov.uk 

 7 & 8 Wellington Place 

Leeds 

LS1 4AP 

22nd March 2022 

Dear Miss Brown 

NHS  Digital  Response  to  Regulation  28  Report  –  inquest  touching  the  death  of  Adam 
Marshall Elliot Stone 

I am writing in response to the Regulation 28 Prevention of Future Deaths report received from 
HM  Area  Coroner  dated  27th  January  2022.  This  follows  the  death  of  Adam  Stone  who  sadly 
passed away on 12th September 2019.  This was followed by an investigation and inquest which 
concluded on 25th January 2022.   

Firstly, I would like to offer my sincerest condolences to Adam’s family. 

NHS Digital were not aware that this inquest was occurring, and therefore we did not have the 
opportunity to provide information to assist your inquiry.    

I am Dr 
NHS Digital.  

, and I am writing in my capacity as Chief Clinical Officer, NHS Pathways, 

NHS Pathways is the clinical decision support software (CDSS) used by all 111 service providers, 
and some 999 ambulance trusts in England.  For information, we have included a short summary 
of the functions that NHS  Pathways performs and the governance that underpins it (containing 
background information on NHS Pathways) in Appendix A. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk

 
 
 In response to the matters of concern outlined in the report:  

1.  Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation 
which  usually  includes  abnormal  physiology  and/or  behaviour.  ABD  is  not  a 
diagnosis  or  a  recognised  syndrome,  but  rather  a  term  used  to  describe  a 
combination of signs and symptoms of aggression and agitation with physiological 
abnormalities, often associated with a cause (drugs, mental  health  disturbance or 
medical condition). The term has been adopted by most healthcare providers in the 
UK. The presenting  behaviour can range from mildly erratic, to a state of extreme 
agitation,  and  physical  exertion.  Patient  has  signs  of  sympathetic  autonomic 
dysfunction,  such  as  significant  tachycardia,  marked  metabolic  acidosis  and 
hyperthermia. These are associated with multi organ failure and death. The incidence 
of sudden death is sometimes quoted as 10% although some studies suggest a much 
higher rate and current research is not sufficient to rely on this figure. Police Forces 
and Emergency Departments regard ABD as a medical emergency  because of the 
risk of sudden death.  

Comments noted. 

2.  ABD has no specific antidote or treatment as it is the underlying cause that needs to 
be identified and treated. However, the main principles of treatment are to calm the 
patient,  cool  them  down  and  provide  supportive  treatment  as  much  as  possible, 
whilst maintaining safety for both the patient and the care providers. Sometimes de-
escalation cannot be achieved, and restraint is required in the interests of the patient, 
members  of  the  public  and  carers.  Physical  restraint  should  always  be  kept  to  a 
minimum because resistance to it increases the physiological burden to the patient 
and  therefore  the  risk  of  death.  Chemical  restraint,  sedation,  is  rarely  available 
outside hospital. Therefore, the key to successful treatment of severe ABD is getting 
the patient to hospital as soon as possible to avoid or minimise restraint. 

Comments noted. 

3.  Currently  NHS  Pathways,  which  is  used  by  West  Midlands  Ambulance  Services, 
categorises ABD (or Excited Delirium as it can also be called) as requiring a category 
2 response. A category 2 response has a mean average response time of 18 minutes 
from categorisation of the call up to a maximum of 240 seconds from the start of the 
call.  It  is  understood  from  the  evidence  that  the  other  triaging  tool  used  by 
Ambulance services in the UK, Advanced Medical Priority Dispatch (AMPDS), also 
gives ABD/Excited Delirium a category 2 priority.  

NHS Pathways is a triage system that assesses symptoms presented at the time of a call and 
directs patients to the most appropriate services based on their described symptoms.  It does not 
provide  a  suggested  diagnosis  or  rely  on  call  handlers  being  able  to  recognise  particular 
conditions.   

Calls from members of the public 
ABD  (also  known  as  Excited  Delirium)  is  not  a  condition  the  general  public  are  familiar  with. 
Therefore, in respect of calls from the public, a specific disposition for ABD will not be provided, 
even if declared by the caller, but rather the symptoms described will be triaged.  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 Any  call  from  a  member  of  the  public  will  undergo  an  initial  assessment  for  immediate  life-
threatening symptoms, including whether the patient has stopped breathing, is choking, is having 
a fit or seizure, is unconscious, has heavy blood loss, is experiencing severe breathing difficulty 
or a life-threatening allergic reaction. If any of these life-threatening symptoms are identified, then 
they  receive  a  disposition  which  is  mapped  to  a  Category  1  ambulance  response.  Should  no 
immediately  life-threatening  symptoms  be  identified,  then  the  assessment  progresses  through 
further questions to establish an appropriate outcome for the clinical condition of the patient.  

Calls from Healthcare Professionals 
Calls which are received from healthcare professionals are dealt with by a different route to the 
general public. For calls received from a healthcare professional, there are initial questions about 
emergency symptoms and those relating to threatened loss of life, limb or sight. If answered ‘no’, 
there is then a question about mental health emergencies, which means an emergency ambulance 
may be required. These questions include determining whether the patient is under active restraint 
or in need of restraint, or whether ABD has been declared.  If any of these situations apply, they 
receive a disposition which is mapped to a Category 2 ambulance response.  

Calls from Police Officers 
Calls from the Police are managed in two different ways, depending on whether the patient is with 
the caller. If the caller is with the patient, then a symptom-based assessment can be undertaken 
in the same way as if the caller was a member of the public. However, when the caller is not with 
the  patient,  it  is  usually  not  possible  to  complete  the  assessment  due  to  a  lack  of  available 
information and therefore a route called ‘early exit’, for a ‘remote observer’ is taken.  

This  includes  questions  on  life-threatening  symptoms,  as  described  above.  If  immediately  life-
threatening symptoms are identified, at any stage, then a disposition is reached which is mapped 
to a Category 1 ambulance response.   

If  there  are  no  immediately  life-threatening  symptoms  further  questions  are  asked  to  identify 
severe and time sensitive issues, including whether ABD has been declared. Any declaration of 
this will result in a disposition mapped to a Category 2 ambulance response.   

Ambulance Responses 
The above reflect the national ambulance frameworks embedded within NHS Pathways. People 
who have undergone  restraint or had ABD declared by the Police or a healthcare professional 
require  a  Level  2  response,  mapping  to  the  Category  2  ambulance  response  standard.  These 
frameworks were jointly developed by the Association of Ambulance Chief Executives (AACE) and 
NHS  England,  with  clinical  support  from  NHS  Digital.  The  national  ambulance  frameworks  are 
owned by NHS England: 

https://www.england.nhs.uk/publication/healthcare-professional-ambulance-
responses-framework/ 
https://www.england.nhs.uk/publication/inter-facility-transfers-framework/ 

NHS England, via its Emergency Call Prioritisation Advisory Group (ECPAG), determines the 
category of ambulance response required for a given triage code and/or clinical condition based 
upon advice received from the Clinical Coding Review Group (CCRG) – also a function of NHS 
England and chaired by an Ambulance Medical Director – and by the National Ambulance 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 Medical Director’s group (NASMeD), a sub-function of AACE. NHS Digital has representation 
within CCRG and ECPAG to help inform their decisions. 

Within  NHS  Pathways,  in  respect  of  requests  for  assistance  from  the  police,  prisons  and 
healthcare  professionals,  the  triage  coding  for ABD  maps  to  the  nationally  agreed Category 2 
ambulance response standard, as instructed by ECPAG. 

We are unable to comment on the process used by AMPDS. 

4.  The inquest heard evidence from 2 expert witnesses, Dr 

 a Consultant 
in Emergency Medicine and a Medical Examiner at Poole General Hospital who sees 
several  cases  of  severe  ABD  a  year  within  his  clinical  practice,  and  Dr 

a Consultant in Emergency and Intensive Care Medicine and a Clinical 
  was  one  of  the 
Toxicologist  at  Barts  Health  NHS  Trust  in  London.  Dr 
authors of the Royal College of Emergency Medicine's Guidelines on ABD and deals 
with cases of ABD every few days in clinical practice. Both experts gave evidence 
that, in their opinion, severe ABD should be given the highest priority by Ambulance 
  explained  that  this  was  his  view  because,  even  though 
Services.  Dr 
category 1 is reserved for patients in cardiac arrest or peri arrest, ABD is unique in 
that it is so difficult for any effective treatment or management to be given outside 
of  hospital  to  prevent  catastrophic  deterioration  and  death,  and,  in  fact,  the  often 
necessary intervention of restraint whilst awaiting an ambulance actually increases 
the risk. Dr 
 view was that if an effective system was used to identify ABD 
it would not create an undue burden on Ambulance Services as it is not a common 
 but did feel that there 
occurrence. Dr 
should be some assessment of severity as mild cases of ABD do not create the risk 
of death that warrants the category 1 response. Dr 
 evidence was that 
restraint could be used as the trigger for a designation of category 1 for ABD given 
that  the  need  for  restraint  both  indicates  that  the  case  is  severe  and  is  actually 
increasing the risk of death.  

 was in agreement with Dr 

The range of symptoms associated with more common emergency medical presentations and the 
unknown, though believed to be rare, incidence of ABD presents challenges for telephone triage 
and the appropriate level of emergency response. Ambulance resources are finite; Category 1 
responses typically result in a robust operational resource by the ambulance service, sometimes 
activating specialist critical care resources and often drawing clinical resources away from other 
emergencies. As a result, there should be a high degree of certainty that a Category 1 response 
is actually required.   

During  the  period  2020-21  an  AACE  led  ‘task  and  finish’  group,  chaired  by  a  senior  medical 
representative from NASMeD, and attended by NHS Digital, considered the appropriateness of a 
Category  1  response  to  ABD  following  a  request  for  emergency  medical  assistance  from  the 
Police.  The  evidence  reviewed,  including  the  results  of  a  pilot  conducted  by  the  Yorkshire 
Ambulance Service with South Yorkshire Police, did not support a Category 1 response. The task 
and  finish  group  presented  to  CCRG,  and  subsequently  to  ECPAG,  a  recommendation  that 
suspected ABD reported by the Police should be responded to as a Category 2 response. ECPAG 
approved this recommendation in September 2021. 

Therefore, any change in ambulance response categorisation would be matters for the respective 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 NHS England and AACE groups to consider, and would need to be approved by ECPAG as a 
function of NHS England. 

5.  The continuance of a system which does not allow a category 1 response in severe 

case of ABD where restraint is taking place is putting lives at risk. 

We would like to  reassure you that  NHS Pathways recognises the risks associated with  ABD/ 
Excited Delirium and also that restraint may be a factor contributing to a patient’s deterioration.   

As  described  above,  NHS  Pathways  is  fully  compliant  with  the  national  ambulance  response 
standard mandated by ECPAG for suspected ABD, with regard to healthcare professionals and 
Police requests for medical assistance. NHS Digital will continue to work collaboratively with our 
stakeholders in the ambulance sector, and under the direction of ECPAG, on the subject of ABD 
as new evidence arises. 

In  2019,  NHS  Pathways  produced  “Spotlight  on:  ABD”  training  materials  to  be  used  by  call 
assessors and clinicians with the 999 emergency operation centres of ambulance services that 
use the NHS Pathways system. This was published to raise awareness of ABD as a rare but very 
serious medical condition which warrants an emergency response.  

If I can be of any further assistance, please let me know. 

Yours sincerely 

Dr 
Chief Clinical Officer 
NHS Pathways 
NHS Digital  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix A 

Function of NHS  Pathways 

BACKGROUND INFORMATION 

NHS Pathways is a programme providing  the Clinical Decision Support System (CDSS)  used in 
NHS  111  and  half  of  English  ambulance  services.  This  triage  system  supports  the  remote 
assessment of  over  1 8  million  calls per  annum.  These  calls  are  managed  by  non-clinical 
specially  trained  call  handlers  who  refer  the  patient  into  suitable  services  based  on  the 
patient’s health needs at the time of the call. These call handlers are supported by clinicians 
who are able to provide advice and guidance or who can take over the call if the situation 
requires  it.  The  system  is  built  around  a  clinical  hierarchy,  meaning  that  life-threatening 
problems assessed at the start of the call trigger  ambulance responses,  progressing through to 
less urgent problems which require a less urgent response (or  “ disposition”)  in other settings. 

Governance  of NHS Pathways 

The safety of the clinical triage process endpoints  resulting from a 111 or 999 assessment using 
NHS  Pathways,  is overseen  by  the National  Clinical  Governance  Group, hosted by the Royal 
College of General Practitioners. This group is made up of  representatives  from  the  relevant 
Medical  Royal Colleges. Senior clinicians from the Colleges provide  independent  oversight and 
scrutiny of the  NHS Pathways clinical content. Changes to the NHS Pathways clinical content 
cannot be made unless there is a majority agreement at NGCC. 

Alongside 
this  independent  oversight,  NHS  Pathways  ensures  its  clinical  content  and 
assessment protocols are concordant with the latest advice from respected bodies that  provide 
evidence  and guidance  for medical practice in the UK.  In  particular,  we are  concordant with 
the latest guidelines  from: 

• 
• 
• 

NICE  (National  Institute  for Health and Clinical Excellence) 
The UK Resuscitation Council 
The UK Sepsis Trust 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk

Miss Emma Brown 
HM Area Coroner for Birmingham and Solihull 
Steelhouse Lane  
Birmingham  
B4 6BJ 

National Medical Director and Interim 
Chief Executive of NHS Improvement 
NHS England & NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

england.coroners28@nhs.net 

29th March 2022 

Dear Miss Brown, 

Re: Regulation 28 Report to Prevent Future Deaths – Adam Marshall Elliot 
Stone who died on 12 September 2019. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27 
January 2022 concerning the death of Adam Stone on 12 September 2019. I would 
like to express my deep condolences to Adam’s family.  

I note the inquest concluded Adam Stone’s death was a result of consequences of 
Cocaine Toxicity and Coronary Artery Atheroma with Acute Behavioural Disturbance.

Following the inquest, you raised matters of concern as follows: 

1.

2.

Acute Behavioural Disturbance (ABD) is an umbrella term to describe a
presentation which usually includes abnormal physiology and/or behaviour.
ABD is not a diagnosis or a recognised syndrome, but rather a term used to
describe a combination of signs and symptoms of aggression and agitation
with physiological abnormalities, often associated with a cause (drugs, mental
health disturbance or medical condition). The presenting behaviour can range
from mildly erratic, to a state of extreme agitation, and physical exertion.
Patients have signs of sympathetic autonomic dysfunction, such as significant
tachycardia, marked metabolic acidosis and hyperthermia. These are
associated with multi organ failure and death.   Police Forces and Emergency
Departments regard ABD as a medical emergency because of the risk of
sudden death.

ABD has no specific antidote or treatment as it is the underlying cause that
needs to be identified and treated. The main principles of treatment are to
calm the patient, cool them down and provide supportive treatment as much
as possible. Sometimes de-escalation cannot be achieved, and restraint is
required in the interests of the patient, members of the public and carers.

NHS England and NHS Improvement 

 3. 

4. 

Physical restraint should always be kept to a minimum because resistance to 
it increases the physiological burden to the patient and therefore the risk of 
death. Sedation is rarely available outside hospital and therefore the key is 
getting the patient to hospital as soon as possible to avoid or minimise 
restraint.  

Currently the triaging tools used by ambulance services, namely NHS 
Pathways and Advanced Medical Priority Dispatch (AMPDS), categorises 
ABD as requiring a category 2 response. A category 2 response has a mean 
average response time of 18 minutes from categorisation of the call, up to a 
maximum of 4 minutes from the start of the call.  

The inquest heard evidence from 2 expert witnesses, who gave evidence that, 
in their opinion, severe ABD should be given the highest priority by 
Ambulance Services. However, one witness did feel that there should be 
some assessment of severity as mild cases of ABD do not create the risk of 
death that warrants the category 1 response. A suggestion was that restraint 
could be used as the trigger for a designation of category 1 for ABD given that 
the need for restraint both indicates that the case is severe and is actually 
increasing the risk of death. 

5. 

The continuance of a system which does not allow a category 1 response in 
severe case of ABD where restraint is taking place is putting lives at risk. 

NHS Ambulance Services are required to process 999 calls through a triage system  
approved by the Department of Health and Social Care.  There are currently two 
systems approved in England for primary 999 assessments: NHS Pathways and 
Advanced Medical Priority Dispatch System (AMPDS).  The outcome (disposition) 
reached at the conclusion of the initial assessment must be mapped to approved, 
contracted standards. There is a requirement to map these outcomes to the various 
categories set out within the NHS Constitution and Ambulance Service 999 
contracts.  The production, maintenance, review and revision of this dataset is the 
responsibility of NHS England and NHS Improvement as the owner of the dataset.  
The ambulance sector within England has a vital role in providing information, 
evidence and expert advice to NHS England and NHS Improvement regarding the 
dataset and the prioritisation of emergency calls.  Both triage systems assign a 
Category 2 (emergency) response to suspected cases of ABD. 

ABD is not common and it is very difficult to identify the difference between agitation, 
antisocial behaviour, deliberate violent behaviour and ABD, which is not a specific 
condition with a set of defined symptoms.  There is no reliable way to determine mild 
or severe ABD in the pre-hospital setting and certainly not on the phone during a 
triage process.   

Category 1 responses are reserved for immediate threat to life illnesses or injuries 
and ambulances are diverted when en-route to other emergencies in order to 
respond to Category 1 patients.  Cases of suspected ABD should be assigned a 
Category 2 response which is the immediate dispatch of an emergency ambulance, 
however, ambulance services are advised that a senior clinician within the control 
room should be made aware of the potential ABD incident to assist with decision-

 
 
 
 
 
 
 making and if necessary, this would in certain situations include upgrading the 
incident to a Category 1 if the patient’s condition indicated that it was appropriate. 
The Association of Ambulance Chief Executives and the Joint Royal Colleges 
Ambulance Liaison Committee (JRALC) issued an update on ABD in January 2021, 
which included additional wording to emphasise the need for close monitoring of a 
patient when restraint is used and that the clinician is clinically responsible for the 
patient. A copy of the JRALC updated guidance is being shared with this PFD 
response. Please note that the guidance has been approved to share with yourself 
and not for circulation or redistribution. 

NHS England and NHS Improvement are in the process of writing to ambulance 
services regarding clinical oversight and will include a reminder that ABD calls 
should have oversight of a senior clinician in the control room and calls should be 
upgraded to a Category 1 if the patient’s condition deteriorates or if the patient is 
being restrained. 

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, 

National Medical Director