Joan Ferguson

Strictly Private and Confidential  
Mrs Carly Elizabeth Henley 
His Majesty's Assistant Coroner for 
Newcastle upon Tyne and North Tyneside 
Civic Centre 
Barrass Bridge  
Newcastle upon Tyne 
NE1 8QH 

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Date: 26 January 2023  

www.neas.nhs.uk 

Dear Mrs Henley, 

Inquest into the death of Joan Ferguson 

Regulation 28 – Report to prevent future deaths  

I am writing in my role as Chief Executive of North East Ambulance Service NHS Foundation 
Trust ("NEAS") and in response to the Regulation 28 report for the prevention of future deaths 
dated 17 December 2022 as issued by you following the inquest into the tragic death of Joan 
Ferguson.   

The matters of concern listed in your report are: - 

1.  During the course of the inquest I heard evidence from the Health and Safety Manager 
at  NEAS.  He  accepted  that  a  risk  assessment  should  have  been  carried  out  prior  to 
every transfer conducted in respect of a complex bariatric patient. Joan was a complex 
bariatric patient and yet received no up to date risk assessment. He stated that this risk 
assessment  should  have  been  carried  out  by  a  Scheduled  Care  Team  Manager  and 
should  have  included  information  taken  from  Joan  and/or  her  family  and/or  clinicians 
involved in her care. 

2.  During the course of the inquest and investigation, the family provided information that 
Joan had fallen on three or four earlier occasions during hospital transfers. NEAS have 
no record of these incidents. I accept the family’s account and am concerned that no 
records were made of these incidents. The absence of recorded incidents prevented an 
accurate risk assessment taking place. 

3.  During the course of the inquest and investigation, I heard evidence from the Health and 
Safety Manager that a dynamic risk assessment should have been conducted during the 
transfer. I heard evidence from the Clinical Support Assistant who should have received 
effective training on dynamic risk assessment. There was no evidence that he performed 
an effective dynamic risk assessment on 3.5.22. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore 
licensed to provide services, by the Care Quality Commission (Provider ID: RX601). 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  During  the  course  of  the  inquest,  the  three  members  of  NEAS  who  effected  Joan’s 
transfer on 3.5.22 each gave evidence. They each accepted that they did not ask Joan 
and/or did not wait for a response from her, did not ask ward staff prior to leaving hospital 
and  did  not  ask  Joan’s  husband  who  was  in  the  vicinity  of  her  home,  prior  to  them 
encouraging Joan to stand, whether she was able to stand safely. Instead, they relied 
on historical information and encouraged her to stand. 

You  will  note  that  we  have  removed  the  names  of  the  Trust  witnesses  from  our  letter  of 
response  and  simply  use  their  position.  I  hope  that  this  is  appropriate  in  considering  the 
response will potentially be published via the Ministry of Justice website. 

We will address each point you have raised in your matters of concern below: - 

1.  During the course of the inquest I heard evidence from the Health and Safety Manager 
at NEAS. He accepted that a risk assessment should have been carried out prior to 
every  transfer  conducted  in  respect  of  a  complex  bariatric  patient.  Joan  was  a 
complex bariatric patient and yet received no up to date risk assessment. He stated 
that this risk assessment should have been carried out by a Scheduled Care Team 
Manager  and  should  have  included  information  taken  from  Joan  and/or  her  family 
and/or clinicians involved in her care. 

The  ’Care  and  Transportation  of  Bariatric  and  Complex  Patients’  procedure  has  been 
updated to provide more robust processes to prevent reoccurrence and strengthen the risk 
assessment process. This applies to those cases classified as ‘patients with complex needs 
and those deemed as bariatric or require complex extrication’.  

The following details are an extract from the enclosed ’Care and Transportation of Bariatric 
and Complex Patients’ procedure. 

‘In the case of a planned journey for Scheduled Care, a risk assessment must be carried 
out  prior  to  the  actual  journey  taking  place.  This  is  to  identify  any  potential  risks  and 
obstacles  that  may  be  present  and  gives  time  to  call  in  additional  help/support  or 
involvement from other agencies. If the patient has previously travelled, this can initially be 
done  over the  telephone.  The Scheduled  Care  Team  Manager should ascertain  whether 
any of the previous risk assessment details have changed and if so, arrange a face to face 
assessment’. 

‘Scheduled Care pre-planned journeys should be booked at least 48 hours in advance, risk-
assessed by a Scheduled Care Team Manager with input from a Clinical Support Assistant  
is  required,  documented  on  the  correct  form  (Patient  Moving  Handling  Risk  Assessment 
Form  &  Plan)  and  sent  electronically 
team 
(special.patient.notes@nhs.net)  and  Patient  Transport  Service  Dispatch  Support.  If  a 
request is made with less than 48 hours’ notice, Patient Transport Service Dispatch Support 
must make contact with a Team Manager via telephone to ascertain if it is possible for the 
assessment to be carried out’. 

the  special  patient  notes 

to 

‘On receipt of a planned journey of a known or suspected bariatric or complex patient, the 
Emergency  Operations  Centre  will  take  the  booking  via  the  Scheduled  Care  booking 
process and then inform Patient Transport Service Dispatch Support who will request the 
assessment  is  undertaken  by  contacting  the  Scheduled  Care  Team  Manager.  Patient 
Transport Service Dispatch Support will provide as much relevant information as possible 
to allow the Team Manager to carry out the assessment’. 

2 

 
 
 
 
 ‘The Scheduled Care Team Manager will contact the patient or person who requested the 
assessment  and  arrange  a  suitable  time  to  attend.  If  the  Team  Manager  feels  specialist 
input is required, then they must make contact and arrange this. Once the assessment has 
been carried out, the Team Manager/ Clinical Support Assistant will complete the relevant 
documentation (Patient Moving Handling Risk Assessment Form & Plan) and send this back 
to Special Patient Notes and Patient Transport Service Dispatch Support’. 

‘The Special Patient Notes Team will place any relevant flags in all Cleric systems prior to 
the  journey  being  undertaken.  The  Patient  Transport  Service  Dispatch  Support team  will 
add notes to any live bookings’. 

The ’Care and Transportation of Bariatric and Complex Patients’ procedure is enclosed to 
provide  full  details  of  the  updated  procedure.  The  procedure  does  cross  into  the  other 
concerns raised within the Prevention of Future Deaths (Regulation 28) Report. 

2.  During the course of the inquest and investigation, the family provided information 
that Joan had fallen on three or four earlier occasions during hospital transfers. NEAS 
have no record of these incidents. I accept the family’s account and am concerned 
that  no  records  were  made  of  these  incidents.  The  absence  of  recorded  incidents 
prevented an accurate risk assessment taking place. 

Internal  investigations  have  not  identified  any  reported  incidents  prior  to  the  incident 
associated  with  the  case. We  have  spoken with  internal and  external partners  to  try and 
identify any incidents. Upon checking the integrated risk management system (Ulysses) we 
have  not  found  any  additional  records  except  historic  safeguarding  referrals  which 
generated the original risk assessment. We cannot find any records of previously reported 
incidents or complaints/concerns raised by our crews/staff.  

The only information we have sourced is from the Investigating Officer who undertook the 
internal investigation into the specific incident. As you know the Investigating Officer was 
not able to attend the inquest due to unforeseen circumstances and with your permission 
another  witness  took  their  place.  We  acknowledge  this  was  not  ideal  nor  helpful  to  the 
inquest and those involved. 

The Investigating Officer re-calls that a member of the EVAC team had advised Joan had 
mentioned a previous fall. It was explained that this occurred when Joan was more mobile 
and  living  upstairs.  The  member  of  staff  has  advised  that  Joan  suggested  the  fall  had 
occurred when going down the house stairs but could not recollect more about it, including 
date, time and circumstances. It is understood it was likely before 2020 but we have not 
identified  any  information  or  evidence  during  our  inquiries.  This  did  not  form  part  of  the 
investigation  report  as  we  could  not  identify  if  the  fall  had  occurred  during  one  of  our 
attendances to Joan. 

External inquiries have included speaking with third party providers which reached the same 
conclusion  with  no  incidents  been  reported  or  recorded.  Internal  inquiries  extended  to 
reviewing  bookings  for  Scheduled  Care  transport  and  emergency  calls  involving  our 
Unscheduled  Care  crews.  Upon  reviewing  the  case  notes  on  each  case/attendance,  we 
have not identified any records to indicate a fall or ‘dropping’ of Joan.  

3 

 
 
 
 
 Due to our inability to identify any historic incidents, we will approach the family to ask if they 
are able to help with further details/information. It is however important to note that during 
our original investigation and liaison with the family, no previous incidents were disclosed. 
The same applies to the inquest, during evidence the family intimated previous incidents 
when Joan was dropped, however no details were provided. 

In  respect  to  the  point  ‘the  absence  of  recorded  incidents  prevented  an  accurate  risk 
assessment  taking  place’.  Whilst  we  acknowledge  that  information  regarding  previous 
incidents  is  important  to  assist  with  risk  assessments,  it  is  important  to  draw  upon  the 
response below. The fact that our staff had not spoken with hospital staff, Joan’s family and 
Joan is a key factor in the effectiveness of the dynamic risk assessment. As heard during 
the  inquest  evidence  provided  by  the  Trust’s  Health  and  Safety  Manager,  dynamic  risk 
assessment was explained as “merely a thought process when things change, and you 
think on your feet, and you might need to change process or put a new risk control 
measure in place to do something safely”.  

In considering a planned risk assessment, then previous incidents would certainly be a key 
consideration  to  help  formulate  effective  control  measures.  We  refer  onto  the  ’Care  and 
Transportation  of  Bariatric  and  Complex  Patients’  procedure  for  more  information  in  this 
regard. 

3.  During the course of the inquest and investigation, I heard evidence from the Health 
and  Safety  Manager  that  a  dynamic  risk  assessment  should have  been conducted 
during the transfer. I heard evidence from the Clinical Support Assistant who should 
have received effective training on dynamic risk assessment. There was no evidence 
that he performed an effective dynamic risk assessment on 3.5.22. 

Whilst  the  crew  did  undertake  a  dynamic  risk  assessment  our  own  internal  investigation 
concluded that they had not established any changes in mobility. This included not seeking 
information from hospital staff or the patient’s family. This fundamentally flawed the quality 
of  the  dynamic  risk  assessment  which  was  therefore  based  on  previous  experience  and 
without clear communication with the patient.   

We can confirm that our operational staff receive dynamic risk assessment training as part 
of statutory and mandatory training and other specific information, instruction, and training. 
In this case the main issues related to the lack of communication/information with hospital 
staff,  Joan’s  family  and  indeed  Joan.  This  factor  is  linked  with  the  fact  the  planned  risk 
assessment  had  not  been  re-visited  in  a  timely  manner  and  the  wider  compliance  with 
existing  procedures.  These  factors  are  addressed  within  the  responses  for  the  related 
concerns raised within the Prevention of Future Deaths (Regulation 28) Report. 

In addition, we can confirm, as per our serious incident investigation report, that information 
has  been  shared  with  staff  in  respect  to  communication,  before  and  during  dynamic  risk 
assessments.  

4 

 
 
 
 
 4.  During the course of the inquest, the three members of NEAS who effected Joan’s 
transfer on 3.5.22 each gave evidence. They each accepted that they did not ask Joan 
and/or did not wait for a response from her, did not ask ward staff prior to leaving 
hospital and did not ask Joan’s husband who was in the vicinity of her home, prior 
to them encouraging Joan to stand, whether she was able to stand safely. Instead, 
they relied on historical information and encouraged her to stand. 

This point is directly linked with the previous concerns and our responses. I will not repeat 
the  information  previously  detailed  and  that  contained  within  the  enclosure.  We  would 
however like to acknowledge that this point was identified within the internal investigation 
report and added into the recommendations/action plan. We can therefore confirm that the 
importance of communication with partners, those involved in the care, families and patients 
has been shared with our staff as a reminder.  

These  factors  and  others  will  be  monitored  via  our  adverse  incident  reporting  and 
investigation  processes,  equally  important  is  the  learning  outcomes  from  such  adverse 
events.  Work  is  on-going  to  strengthen  internal  processes  to  ensure  the  triangulation  of 
information and intelligence to help improve the experience, quality and safety of service 
services users.   

I hope that this addresses the matters of concern which you have highlighted.  

Yours sincerely 

Chief Executive 

Enclosure 

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