Lauren Smith

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

HM Coroner Mrs Joanne Lees 
Coroner’s Court  
Jack Judge House  
Halesowen Street 
Oldbury 
B69 2AJ 

8 January 2023 

Care Quality Commission 

Dear HM Coroner 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Miss 
Lauren Page Smith 

Thank you for sending CQC a copy of the prevention of future death report 
issued following the death of Miss Lauren Page Smith. The report identifies 
concerns about the care provided by West Midlands Ambulance Service NHS 
Foundation Trust on 6 January 2023. 

We note the legal requirement upon us to respond to your report within 56 days. 

Your prevention of future death report asks CQC to respond to the following 
information raised in point 14 of the report: 

‘I am concerned that there has been no collective learning by West Midlands 
Ambulance Service following the death of Lauren Smith. There has been no 
action to address the learning gaps identified by WMAS own internal 
investigation report in respect of both the paramedic and technician. Therefore, I 
have addressed this aspect of my PFD to the CQC/Chief Inspector of 
Hospitals/HSIB as part of their regulation as to the safety of the West Midlands 
Ambulance Service considering the risk I have identified in relation to patient 
safety due to inaction by WMAS’. 

We carried out core service inspections of WMAS covering urgent and 
emergency care and the emergency operations centre on 15 to 17 August 2023. 
An inspection of the well led key question was also carried out between 3 and 5 
October 2023. The draft report for these inspections is currently with the provider 

1 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 for a factual accuracy check. We will share the report with you when it is 
finalised. 

During our inspection, we identified the need for improvements to be made to the 
processes around serious incident management and learning from deaths. 
Specifically, there was a focus at the trust around the quantity and timeliness of 
serious incident investigations rather than on the learning required as a result of 
the outcome of the investigations.  

As you may be aware, CQC has been the lead enforcement body for health and 
safety incidents in the health and social care sector since 1 April 2015. As such, 
we contacted WMAS and requested evidence of the action they had taken to 
date following Miss Lauren Page Smith’s death and any additional action they 
intended to take in response to the prevention of future death report. 

Having carefully reviewed the information the trust has provided, we have 
concluded there is no evidence of provider level failing in relation to Miss Lauren 
Page Smith’s death. However, we did identify concerns that supported our 
inspection findings in relation to the serious incident investigation process, and in 
particular, the timeliness around addressing the training needs of the staff 
involved with Miss Lauren Page Smith’s care. 

The updated WMAS action plan dated 2 November 2023 and our ongoing 
communications with WMAS has demonstrated that the training needs of one 
staff member have now been addressed and the second staff member’s training 
needs will be met on their return to work.  

We will continue to monitor WMAS’s progress in making improvements to their 
serious incident management and learning from deaths through our ongoing 
monitoring activities and engagement.  

Yours sincerely 

Deputy Director of Operations, Midlands Network 

2

Black Country Coroner’s Services 
Coroner’s Court 

Health Services Safety  
Investigations Body 
Executive Office of the CEO and Chair 
ExecutiveOffice@hssib.org.uk  

09 January 2024 

Dear Coroner, 

RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) 

Thank you for sharing this report with the Health Services Safety Investigation Body 
(HSSIB), we are sorry to hear of Lauren’s death and to read the findings within your 
report. 

On 20 December 2023, our Investigations and Insights team held an Intelligence 
Review Meeting; at this meeting we review all patient safety concerns and insights 
received into our organisation and consider them for further exploratory work. I would 
like to assure you that the Regulation 28 Report sent to us was considered in this 
meeting, along with other information available to us and I can confirm that further 
exploratory work is being undertaken in relation to the issues raised in your report. 

This exploratory work will be further reviewed by the end of January 2024 when we 
will consider the scope for an HSSIB investigation into issues related to Paramedic 
interpretation of ECGs in the community. 

Yours sincerely 

Interim Chief Executive Officer

Private and confidential 

Joanne Lees 

19 December 2023 

Dear Joanne Lees, 

Health and Care Professions Council 

I write to acknowledge receipt of your email dated 9th November 2023. 

The Fitness to Practice Triage team reviews all new concerns that the 
HCPC receives to decide whether a concern is within the HCPC remit. We 
can only investigate concerns that raise questions about an HCPC 
registrant’s fitness to practise. This means that the individual concerned in 
the matter must have an active registration with the HCPC. 

A review of our Register has revealed that 
with us. As the individual is not registered with us, these concerns do not 
fall within our remit for further investigation. 

 is not registered 

However, I have added her name to our Watchlist. This provides that 
should she attempt to apply for registration in the future, we will take the 
concerns you have raised with us into account when considering whether 
to admit her name to the HCPC Register. 

You can find out more about the Fitness to Practise process via our 
website at: www.hcpc-uk.org. 

Thank you for taking the time to raise this matter with us. 

If you have any questions or queries, please email us at the following 
address ftp@hcpc-uk.org. Alternatively, please do not hesitate to contact 
the department on 

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Triage Officer

WOLVERHAMPTON 

15 January 2024 

Coroners Court 
Jack Judge  House 
Halesowen Street 
Olbury 
B69 2AJ 

For the attention of Joanna  Lees 

Dear Madam, 

Regulation  28 Report to Prevent Future  Deaths 
Inquest into the death of Lauren  Page 

We acknowledge  receipt of your Regulation  18  Report to Prevent Future Deaths. 

We  have  considered  the  Report  and  have  sought  to  provide  you  with  an  overview  of the  training 
programme  undertaken  at  the  University  of Wolverhampton  on  the  BSc  (Hons)  Paramedic  Science 
(Professional  Pathway)  programme. 

The  key points as they relate to the University of Wolverhampton are  points 9 and  13 . 

In  respect of Ms Smith, we have  reviewed our admissions data and  Ms Smith has no known affiliation 
to the  University of Wolverhampton  and  did  not undertake  her paramedic training at the  University 
of Wolverhampton . 

Student paramedic 

 undertook her Associate Ambulance Practitioner (AAP) course with 
Student paramedic
West Midlands Ambulance Service University NHS  Foundation Trust (WMAS)  prior to starting her BSc 
(Hons)  Paramedic  Science  (Professional  Pathway)  programme  at  the  University of Wolverhampton. 
The  AAP  programme  is  a  level  four  apprenticeship  that  is  run  by  WMAS  against  the  agreed 
apprenticeship standards . 

The  apprenticeship  standard  and  teaching  around  ECG  interpretation  materials  are  included  for 
completeness (Appendix A and Appendix B) . It should be  noted that ST-elevation is discussed  on slide 
40 and  pathological Q waves are discussed on page 42 of item 2. 
 would have undergone 
these sessions when she  was  undertaking her AAP  training with WMAS.  Also  included at Appendix C, 
is  a copy of the  PowerPoint presentation on  ECG  arrhythmias  used  by WMAS,  and  at Appendix  D,  an 
ECG  workbook used  by WMAS . 

University of Wolverhampton, Offices of the Vice-Ch ancellor, City Campus Wulfruna, Wolverhampton WVl lLY,  United Kingdom 

T: +44 01902 321000  W: www.wlv.ac.uk 

.,,  __ 

. 

- -

~

-

,, 

THE  UNIVERSITY  OF  OPPORTUNITY 

 
  commenced  her education  at the  University  in  June  2022,  and  is  not due to  complete 
her  studies  until  January  2024.  It  is  important  to  emphasise,  that 
  is  not  a  registered 
paramedic and  will not be eligible to apply for professional registration until such time as she  has met 
all  of the outcomes of her current programme of study.  As  a student, 
 does not have  all 
of the competencies and skills of a registered paramedic so would be working with a practice educator 
who  is  there to  support and  supervise  her as  she  develops  those  competencies  and  skills.  It  is  not 
expected  that  she  would  be  making  independent  decisions  on  patient  care  whilst  in  her  role  as  a 
student paramedic.  The  practice  educator will  always  have  the  ability to  override  the  decision  of a 
student should they deem the proposed course of action to be  sub-optimal for the  patient. 

It  should  also  be  noted  that  on  the  6 January  2023, 
WMAS and  was  not there  in  her student capacity. 
associate ambulance practitioner. 

  was  working  as  an  employee  of 
 was  working within the  remit of an 

At the time of the incident, 
 had  not undergone the full  ECG  interpretation sessions so  it 
may  be  reasonable for her to say that she  did  not have  the full  understanding of the  meaning of the 
ECG  at that time.  The  uncontrolled  nature of paramedic placements means that it is  not uncommon 
for students to encounter situations in  practice  where they have  not yet had the training. Placements 
are  spread  throughout  the  programme  and  the  focus  for  development  changes  as  the  student 
progresses.  The  risks  associated  with  this  are  ameliorated  by  placing  a  student  with  a  registered 
paramedic who is  responsible and  accountable for the clinical  care  of all  patients. 

The  sessions  on  12-lead  ECG  interpretation  were  delivered  on  the  30  June  2023 .  Appendix  E is  the 
scheme  of work  for  the  level  6  module  on  the  Paramedic  Programme  currently  being  sat  by 

  The scheme of work provides an  outline of what is taught in  relation to cardiac physiology 
and  ECGs, although it should  be  noted that ECGs  are re-visited throughout the teaching as  and  where 
appropriate .  Pa rticula r  note  should  be  taken  of sessions  6  and  29,  which  identify  specific  teaching 
around  the  ECG  and  its  relation  to  emergency  conditions.  Also  appended  is  Apper:,dix  F,  which  is 
combined  presentations on  ECGs  and  taught across  multiple sessions.  You  will  note that the  ECG  in 
relation  to  cardiac  emergencies  commences  from  slide  161  with  ST-elevation  myocardial  infarction 
discussed from slide 165 and specific reference to pathological Q-waves on slide  166.  There are other 
slides  that  discuss  pathologies  impacting  the  QRS  complex  as  well  as  the  other  waves  of the  ECG. 
Please  note, these are  not didactic teaching sessions,  the presentation is  there to support learning. 

Please  be assured that ECGs are summatively assessed  in practice (appendix G)  by a student's Practice 
Assessor  and  do  therefore  feature  within  the  University  of Wolverhampton  programme.  Practice 
assessors  are  registered  healthcare  professionals  (usually  Paramedics)  who  have  undertaken 
additional  training  to  support  and  assess  students.  A  Registrant  must  meet  the  Standards  of 
Proficiency of the Health and  Care  Professions Council  (HCPC)  in  order to remain on the Register, so  it 
is  reasonable to conclude that they have the skillset to assess trainee paramedics. 

To  provide  assurance  to  the  Coroner the  assessment  process  in  practice  is  described  below with  a 
table showing how the  modified Bondy system  is  used  in  clinical  practice . 

Assessment Process - Formative and summative assessment 

The  assessment  of each  competency  consists  of formative  assessment  and  summative  assessment. 
Formative  assessment  refers  to  what  is  learnt and  how it is  learnt.  This  should  involve  a continuing 
and  systematic  appraisal  of  the  students'  performance  throughout  their  clinical  placement  to 
determine the degree  of mastery of the given  learning task.  It also  helps to focus  on  the  particular 
learning necessary to achieve  mastery of the required competences.  Formative assessment is  linked 
to the  initial  and  midpoint interviews and  is  part of the continuous assessment.  The  purpose  of the 

 
 interviews  is  to  identify the  learn ing  needs  and to  discuss  the  student's progression .  This  w ill  allow 
the student to observe, discuss and  practice the skill  in preparation for their summative assessment. 

Summative assessment refers to what to learn  and  what counts.  This  is  linked  to the final  interview, 
and  this  will  determine  whether  the  student  can  competently  and  consistently  undertake  the 
competence without direct supervision in a safe, effective manner to ensure they are fit to practice at 
the point of reg istration with the  Health and  Care  Professions Council as  a Registered  Paramedic. 

The key point, with in the summative assessment, is  highlighted and  noted above and goes to the point 
that  a  student  is  dee m ed  to  be  fit  to  practice  at  the  point  of  regist ration  w ith  the  Hea lth  Care 
Professions Council as  a Registered  Paramedic. 

Assessment of Learning - Educational Taxonomy 

To  determine the achievement of competences the assessment process is  based on the Bondy (1983) 
crite rion-referenced definitions for rating scales  in  clinical  evaluation.  This system  allows mentors to 
evaluate student performance against the standard of procedure (safety and  accuracy), the quality of 
the  pe rformance,  and  the  level  of  assistance  requ ired  by  the  student.  The  Practice  Assessment 
Document (PAD) allows the student to show cont inu ing progress ion throughout the placemen t  period 
and encourages mentors to allow sufficient time for students to demonstrate competence over a wide 
range  of presentations and  patient groups  before signing off a student as  ' independent' .  The  more 
evidence  that  is  generated  for  each  competence,  the  more  robust  the  decision  so  it  is  usual  for 
students to continue to work through each of the competences even when they have been signed  off 
at  the  appropriate  level  on  a  number  of  occasions .  This  will  help  to  ensure  that  standards  are 
maintained and that students are not signed off too early when there is insufficient evidence available . 

Figure  1. The  Five-Point Bondy Rating Scale 

Level 

Standard of Procedure 

Quality of Performance 

Level  of Assistance 

Independent 

5 

• Safe  and  accurate each time 

•  Proficient, coordinated 

Without supporting cues 

and  confident 

• Achieved  intended outcome 
Behaviour is  appropriate to 
context 

•  Occasional expenditure 

of excess energy 
•  Within an  expedient 

time period 

Supervised 

4 

•  Safe  and  accurate each 

t ime 

•  Achieved  intended 

outcome Behaviour is 
appropriate to conte xt 

Assisted 

3 

• 

Safe  and  accurate each 
time 

Marginal 

2 

•  Ach ieved  most objectives 
for intended outcome 

•  Behaviour generally 

appropriate to context 

• 
Safe  only with guidance 
•  Not completely accurate 
• 
Incomplete achievement 
of intended outcome 

Occasional supportive  cues 

• 

• 

Efficient, coord inated 
and  confident 
Some expend iture of 
excess  energy 
•  Within a reasonable 

time period 
•  Skilful in  part of the 

• 

behaviour 
Inefficiency and 
incoordination 

•  Expends excess energy 
•  Delayed time period 
•  Unskilled,  inefficient 
•  Considerable 

expenditure of excess 
energy 

•  Prolonged time period 

Frequent verbal and 
occasional  physical  cues  in 
addition to supportive cues 

Continuous verbal and 
frequent physical  cues 

 Dependent 

1 

Not Observed 

X 

Unsafe 
Unable to demonstrate 
behaviour 
Lack of insight into 
behaviour appropriate to 
context 

Unable to demonstrate 
behaviour/procedure 
Lacks confidence, 
coordination and 
efficiency 

Continuous verbal and 
physical cues 

Adapted from Bondy,  K.  N.  (1983}. Criterion-referenced definitions for rating scales in  clinical 
evaluation. J Nurs Educ,  22(9):376-382 . 

Fitness to Practice 

In  response  to  point 13  regarding  Fitness to  Practice  (FtP),  it is  pertinent to state that the  University 
of Wolverhampton  has  its own robust  FtP  processes that relate to all  students registered  on  courses 
of study that lead  to  provisional or full  registration  with  an  appropriate statutory or regulatory body 
or  which  confer  a· professional  qualification  or  entitlement  to  practise  a  particular  profession  or 
calling.  For courses  leading to eligibility to apply for registration with the HCPC,  students are  required 
to  adhere  to  the  Guidance  on  Conduct  and  Ethics  for  Students  (HCPC,  2016}  throughout  their 
programme. Students also work towards achieving the Standards of Proficiency required to meet the 
HCPC  criteria,  but they are  not expected  to  demonstrate competence  in  all  of these  Standards  until 
close to the point of registration. 

At the time of the incident, 
 was working as an employee of WMAS and not in her capacity 
as  a  student  on  placement.  As  such,  WMAS  did  not  notify  the  University  of the  incident  and  we 
remained unaware of it until two days prior to the receipt of the Regulation 28  report.  Had  we known 
earlier,  we  may  have  considered  whether a  referral  to  an  FtP  panel  was  appropriate,  but  it seems 
unlikely that the event would have met the criteria for referral. 
 still had  over 15-months 
of her programme remaining (including the sessions on  ECGs},  and  she was working with a registered 
paramedic who held overall responsibility and  accountability for the decisions made. 

Steps taken by the University of Wolverhampton 

The  University  understands  and  accepts  without  reservation  that  its  training  must  be  effective . We 
have  reviewed  all  of the  ECG  training  and  assessment  that takes  place  on  the  programme  and  are 
confident  that  our  teaching  fully  covers  the  abnormalities  found  in  the  ECG 
in  this  case,  the 
pathological implications of such  findings,  and  the appropriate course of action to be  taken. 

However,  we  are  completely  committed  to  ensuring  the  safety  of  the  public  so  will  implement 
additional steps to further minimise the risks associated  with the failure to accurately interpret a 12-
lead  ECG. 

Evidence  from  the  case  will  be  presented  to  students to  exemplify the  potential  harm from 
inadequate  understanding  of  the  ECG  and  the  implications  for  the  patient  - we  would 
welcome a copy of the ECG  if this is  possible 
Interpretation  of  12-lead  ECGs  will  be  incorporated  into  one  or  more  of  the  Objective 
Structured  Clinical  Examinations  that  students  sit  throughout  their  programme.  This  will 
supplement rather than replace the current assessments  in  practice. 
Members  of  the  paramedic  team  are  liaising  with  local  coronary  care  units  to  obtain 
anonymised  12-lead ECG  readings from real  patients to further enhance the teaching 

 •  A 12-lead  ECG  interpretation workbook will be  added  to the virtual  learning environment for 
completion  by  students. Students  who  do  not complete  the  activity  will  be  followed  up  by 
their personal academic tutor 

•  The  University will organise continuing professional development ECG  masterclasses to offer 

to registered  paramedics 

Yours faithfully 

Chief Operating Officer

Mrs J Lees 
Area Coroner for Black Country 
Jack Judge House 
Halesowen Street  
Oldbury 
B69 2AJ 

23 November 2023 

Dear Mrs Lees 

Re: Regulation 28 Report to Prevent Future Deaths – Lauren Page Smith 
(Deceased) 

Thank you for your email dated 15 November 2023 attaching your Regulation 28 Report.   

On behalf of West Midlands Ambulance Service (WMAS), I am sorry that you have had to 
raise concerns following the inquest of Ms Smith.  May I please take this opportunity to 
pass on my sincere condolences to the family of Ms Smith. I am deeply saddened by this 
case.  

Our Trust prides itself on the training and education provided to our staff and overall patient 
safety, therefore it is disappointing that our Serious Incident investigation did not reflect 
this.  I hope that our responses to your concerns below together with the evidence you 
heard  in  court  from 
  will  provide  you  with  assurance  in  our  training  and 
education and patient safety. 

Concern 1 
An ecg reading was taken at 08:56 am when both the paramedic and technician were in 
attendance  on  Miss  Smith.  That  ecg  was  abnormal.  The  ecg  identified  pathological  Q 
waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. 
Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the 
ecg. In  addition, the  auto diagnostic monitor  clearly recorded  the  ecg  as  abnormal  and 
reported an anterior infarct which was available for attending paramedics.  

Response 
It is accepted by the Trust that the ECG taken at 08:56am was abnormal. The Zoll monitor 
clearly  reported  this  as anterior  infarct  and the patient  should have been transferred  to 
hospital in accordance with existing established policy. 

Concern 2 
Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg 
was  not  interpreted  correctly  by  either  the  paramedic  technician  or  the  attending 
paramedic with over 8 years’ experience.  

Page 1 of 10 

 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response 
It is accepted by the Trust the interpretation of a 12 lead ECG including the auto diagnostic 
system employed by the Zoll is a fundamental part of the job of a paramedic, which is why 
we provide comprehensive education, training and regular refresher training and provide 
the very best diagnostic equipment such as the Zoll ECG monitor.  

Concern 3 

 gave evidence at inquest that she’d never heard of Q waves before and 
didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves 
nor an AVR positive deflection.  

Response  

  attended  paramedic  training  from  23  February  2015  at  Staffordshire 

University, and the relevant sections from the programme are detailed below.  

Institute for Health Care Development and Paramedic Science Diploma with Staffordshire 
University (IHCD Student Paramedic Training Programme) 

WMAS  Clinical 
Progress  and 
Practical 
Record 

Module D4.3  
page 36 
D5.1 
Pages 40 & 88 

WMAS  Clinical 
Progress  and 
Practical 
Record 
Student 
Paramedic 
Course 

Cardiac 
Monitoring 

Appendices attached for IHCD and Diploma 

Cardiac monitoring – Appendix 1 
Clinical Skills module – Appendix 2 
D4:3  CARDIAC MONITORING 

•  Assist in positioning the patient on a firm surface 

ready for cardiac monitoring/defibrillation. 

•  Correctly  position  the  electrodes  and  leads  as 
directed and an interpretable ECG is obtained. 

•  Avoid 

inflicting 
injury/discomfort to the patient. 

any 

unnecessary 

•  Maintain the dignity and wishes of the patient at 

all times. 

•  Seek any clarification of instructions and pass on 
the 

any  wishes 
practitioner/rescuer immediately. 

patient 

the 

of 

to 

Key learning points; 
The importance of following directions and notifying the 
practitioner  /  rescuer  of  any  changes  in  the  patient’s 
condition. 
Principles of patient sensitivity. 
Equipment types, use and application. 
The importance of patient consent. 
W.M.A.S. Additional Requirements. 

Review of electrical conduction system of the heart. 
Interpretation of a Normal Sinus Rhythm E.C.G. 
Introduction of E.C.G. analysis plan. 
Recognition and interpretation of: 

• 
• 
• 
• 
• 
• 
• 

N.S.R. 
V.F. 
V.T pulse / pulseless. 
Asystole. 
Sinus Tachycardia / Bradycardia. 
PVC’S 
P.E.A. 

D5:1  CARDIAC MONITORING / DEFIBRILLATION 

Page 2 of 10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Correctly position the electrodes and leads and ensure 
an interpretable ECG is obtained. 

Patient Assessment Scenario  

•  Breathing – Rate / Rhythm / Volume 
•  SP02 
•  Peak Flow 
•  Pulse - Rate / Rhythm / Volume 
•  Colour / Temperature / Texture of skin  
•  Capillary refill 
•  Blood pressure 
•  ECG 6 or 12 lead 
•  Temperature 
•  Blood sugar reading 
•  GCS 
•  FAST 

The Trust can confirm that it provides a full day of clinical updates annually in addition to 
  undertook  these 
other  statutory  and  mandatory  training.  The  dates  that 
clinical updates, which covered Q waves and ST elevation, are included below. Only the 
sections relevant to ACS (acute coronary syndrome) care and ECGs are included in this 
table.    

Relevant mandatory refresher clinical training for the last four years 

Training 
Year 

Date 
complete 

Course 
Type 

Summary of training 

Timetable 
or  guide 
learning 
Total 
(mins) 

2020-21 

19.11.20 

2021-22 

20.01.22 

2022-23 

01.09.22 

2023-24 

07.11.23 

Clinical 
Update 

Clinical 
Update 
Clinical 
Update 

Clinical 
Update 

Total 

vs  Pulmonary 

Hyperventilation 
Embolism 
(Appendix 3) 
ACS, 12 lead ECGs, Zoll Analysis 
(Appendix 4) 
Patient Safety - ACS case study, 12 
Lead ECG, Zoll analysis 
(Appendix 5) 
ACS,  STEMI  inc  progression  of  a 
STEMI and pathological Q waves 
(Appendix 6) 

90 

60 

60 

60 

270 

 was a clinical team mentor (CTM) for the Trust at the time of this incident, 
this role requires her to train other paramedics in specific clinical areas. As part of her role 
as a CTM she received the following CTM training.  

Page 3 of 10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CTM Mandatory Training 

Training 
Year 

Date 
complete 

Course 
Type 

Summary of training 

2020-21  01.03.21 

2021-22  30.03.22 

2022-23  17.03.23 

Total 

Clinical 
Update 
Clinical 
Update 
Clinical 
Update 

Clinical Decision Making  - ECGs 
(Appendix 7) 
Bias, ACS case reviews 
(Appendix 8a and 8b) 
Learning  from  adverse  incidents  - 
Zoll data in investigations 
(Appendix 9) 

Timetable 
or guide 
learning 
Total 
(mins) 
90 

60 

60 

210 

Furthermore,  the  JRCALC  (Joint  Royal  Colleges  Ambulance  Liaison  Committee) 
guidelines for Non - Traumatic Chest Pain/Discomfort (Appendix 10) provides guidance 
on ECG’s and accompanying features.  These can be accessed via a mobile phone, an 
individual Trust issued ipad or an Electronic Patient Record (EPR) device, all of which are 
provided by the Trust.  

Concern 4 
Technician 
 told me she had never heard of pathological Q waves and that 
she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on 
the ecg.  

Response  

  undertook  an  ECG  assessment  on  4  August  2020  as  part  of  her 
Technician training (Appendix 11) which tested her knowledge on ECG interpretation, she 
passed this assessment with a score of 92.5%. This assessment covered Q waves and 
ST elevation. 

 has also undertaken the following ECG training on her technician training 

course; 

Level 4 Associate Ambulance Practitioner Course from May to August 2020 

Component 
No 

Session Title  Summary of training 
(Appendix 12a – 12f) 

Timetabled 
Time (mins) 

15                      Cardiovascular 

Examination 

Principles  of  pain  assessment, 
physiological  measurements  and 
common deviations.  

240 

Page 4 of 10 

 
 
 
 
 
 
 
 
 
 ECGs 

19                       Cardiovascular 

Conditions 

ECG 
Fundamentals, 
electrical 
the  heart, 
conduction  system  of 
PQRST  waveform,  ECG  monitoring 
preparation,  4 Lead  ECG,  Paper  and 
timings  and  11  point  guide.  Sinus 
Rhythms,  ACS,  STEMI,  NSTEMI  & 
Supraventricular  rhythms,  conduction 
abnormalities, ventricular rhythms and 
non-shockable  rhythms  of  cardiac 
arrest.  12  lead  ECG  Placement,  12 
lead ECG - views of the heart, 10 rules 
of  the  ECG,    Stable  Angina,  ST 
segment  abnormalities,  ST  segment 
posterior  MO,  ST 
recognition, 
Depression,  ST  Elevation,  ECG 
Interpretation, Primzmetal Angina and 
Ventricular Paced Rhythms.  
Understand  the  pathophysiology  and 
management 
cardiovascular 
of 
system 
Be  able 
medical  conditions, 
with agreed ways of working. 

to  assess  and  manage 
in  accordance 

240 

240 

disorders.                                                            

Total 

720 

The Trust can confirm that it provides a full day of clinical updates annually in addition to 
 undertook these 
other statutory and mandatory training. The dates that 
clinical updates, which covered Q waves and ST elevation, are included below. Only the 
sections relevant to ACS (acute coronary syndrome) care and ECGs are included in this 
table.    

Relevant mandatory refresher clinical training 

Training 
year 

Date 
completed 

Course 
Type 

Summary of training 

Timetable 
or guide 
learning 
Total 
(mins) 

2021-22 

28.09.21 

2022-23 

01.06.22 

2023-24 

09.09.23 

Total 

Clinical 
Update 
Clinical 
Update 

Clinical 
Update 

ACS, 12 lead ECGs, Zoll Analysis 
(Appendix 2) 
Patient  Safety  -  ACS  case study,  12 
Lead ECG, Zoll analysis 
(Appendix 3) 
ACS,  STEMI  inc  progression  of  a 
STEMI and pathological Q waves 
(Appendix 4) 

60 

60 

60 

180 

Page 5 of 10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 JRCALC (Appendix 10) guidelines for Non- Traumatic Chest Pain/Discomfort would also 
be available to 
 via the EPR device, etc, all of which are provided by the 
Trust.  

Concern 5 
The ecg  print  out  clearly  indicated  a  cardiac event  in  progress  at  the time  the  ecg  was 
taken. 

 died from an acute MI.  

Response  
The Trust accepts that a cardiac event was in progress.  

Concern 6 
I am concerned that neither the paramedic nor the technician was able to interpret the ecg 
correctly  and  that  neither  paramedic  appears  to  have  noted  or  acted  upon  the  auto 
diagnostic monitor report.  

Response  
All  our  clinicians  have  received  education  and  training  on  ECG  intrerpretation  some  of 
which is as evidenced within concern 3 and concern 4.  

As part of the Trusts ongoing education and training for staff we have undertaken a range 
of  initiatives  to  improve the  understanding  of  ECGs  and the  auto diagnostic function  of 
ECGs. 

The  Trust  have  issued  a  number  of  articles  to  educate  staff  on  the  use  of  the  auto 
diagnostic monitor. 

Appendix 13 - Clinical Times issue 39 – issued on 10 April 2019 
Appendix 14 - Clinical Times issue 45 – issued on 30 November 2022 
Appendix 15 - Clinical Times issue 49 – issued on 11 September 2023 

Prior to the inquest there were a number of clinical improvements undertaken in relation 
to  cardiac arrest cases, these were; 

January 2023 

•  The Trust delivered a session to CTM staff at Lichfield Hub on STEMI Care/Safety 
themes regarding the discharge on scene of ACS (Acute coronary syndrome) 
•  There was a CPD day at Erdington hub alongside the Research team to provide 
presentation on STEMI clinical times article on ACS and the new JRCALC update, 
including the ambulance quality indicators and time from 999 call to inflation of a 
balloon in a specialist coronary catheter  

February 2023 

•  Engagement with Zoll medical to provide ECG recognition and ALS (Advanced Life 

Support) sessions to staff – 2 free sessions delivered 

•  Review of cases of all non-traumatic chest pain discharged at scene vs the clinical 

risk assessment tool 

March 2023 

•  Development  of  monitoring  of  on  scene  time  for  crews  at  cases  of  STEMI  as 
defined  by  the  national  ambulance  quality  indicators  taken  to  the  national  audit 
group 

•  Article in Weekly Brief on gender disparity in cardiac care 

April 2023 

Page 6 of 10 

 
 
 
 
 
 
 
 
 
 
 
 •  Evening training session on ECGs and Resus skills delivered 

May 2023 

•  Further  sessions  of  education  delivered  in  evening  on  ECG  and  resus  skills 

alongside Zoll 

June 2023 

•  Delivered  in  person  CPD  (Continuing  professional  development)  event,  which 

included ECG skills and recognition 

•  The  Trust  began  contacting  crew  in  cases  of  STEMI  where  AQI  (Ambulance 

Quality Indicators) was not met to explore reasoning  

August 2023 

•  ACS  discharge  on  scene  case  study  published  in  clinical  times,  including 

information on Zoll automatic interpretation data 

•  Article published in weekly brief linking to ACS educational Resources learning 

September 2023 

•  52 ECG cases reviewed by WMAS senior clinical leads group, publishing in our 
weekly  briefings  &  clinical  times  began  on  these  cases  to  share  learning  with 
clinical staff 

•  Microsoft teams channel set up for regular publication of ECG case studies and to 

allow for discussion 

Concern 7 

 was informed that her observations and ecg were normal. This information 
 based her decision not to attend hospital 

was not correct, and it is likely that 
on this incorrect information.  

Response  
It is accepted by the Trust that the information provided to 
relation to the ECG was incorrect. 

 by the clinician in 

Concern 8 
I  was  told  in  evidence  that  paramedic  training  includes  identifying  Q  waves  and  ST 
elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was 
a view) was not ‘normal’ and should have been identified as abnormal. I was told that the 
diagnostic monitor display reported what was seen on the ecg.  

Response  
Q wave changes and AVR deflection does feature in our training but is not a significant 
feature, as this is high level ECG competency.  The ECG auto diagnostic did identify an 
abnormal ECG and this should have been acted upon. 

Concern 9 
I heard in evidence that ecg interpretation forms part of a paramedics initial training and 
mandatory annual training, but I am concerned that there was no evidence at inquest of 
any  qualitative  assessment  of  the  ecg  aspect  of  their  training.  I  was  informed  that 

Page 7 of 10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   was  undertaking  a  Paramedic  BSc  at  Wolverhampton  University. 
Technician 
The  training  provider  and/or  regulator  must  ensure  that  training  is  effective.  I  am 
concerned the absence of such assessment presents a risk to patient safety at this time.  

internally  delivered 

Response  
In addition to the training evidenced in response to concern 3 & 4, the Trust can confirm 
that  all 
includes  qualitative  ECG 
assessments. 
 undertook an ECG assessment on 4 August 2020 as part 
of  her  Technician  training  (Appendix  11)  which  tested  her  knowledge  on  ECG 
interpretation,  she  passed  this  assessment  with a  score  of  92.5%.  This test  covered  Q 
waves and ST elevation. 

initial  paramedic 

training 

The Trust regularly meets with each of its partner universities at its contract meetings. The 
course provision is reviewed regularly to ensure it meets the requirements for both WMAS 
and the HCPC. 
 has not yet completed the full University BSc training at 
the University of Wolverhampton.  

Concern 10 
I heard in evidence that neither paramedic nor technician had received any further training 
from WMAS following the death of 
 and the internal SI investigation which 
specifically identified the incorrect interpretation of the ecg. I am concerned this presents 
a risk to patient safety at this time 

Response 
The  Trust  accepts  that  this  should  have  been  rectified  following  the  Serious  Incident 
investigation.    The  Trust  can  provide  assurances  that  although  there  was  no  further 
specific  formal  training  documented  as  part  of  the  Serious  Incident  investigation  both 
clinicians attended a root cause analysis meeting on the 7 March 2023 which forms part 
of the Serious Incident and learning process.  

The  clinicians  also  completed  clinical  supervision  shifts. 
shift on 26 July 2023 (Appendix 16) and 
(Appendix 17). 
her role as a CTM.  

 completed  this 
 completed her shift on 11 July 2023 
 also completed a CTM update day on 17 March 2023 due to 

Both  the  clinicians  are  booked  to  attend  training  school  for  remedial  training  on  the  1 
 will be meeting with the Trust’s Consultant 
December 2023.  In addition to this 
Paramedic who is the Head of Clinical Care, 
 to review and reflect on the 
ECG abnormalities as part of an additional self reflection request. 

Since the incident 
further her knowledge on ECG’s. 
attend a level 6 ECG in practice course, commencing in January 2024.   

 has also requested to attend a level 6 university course to 
 has been approved and supported by WMAS to 

Concern 11 
I  am  concerned  that  whilst 
  may’ve  undertaken  their  own 
additional  learning/self-reflection  NO  qualitative  assessment  of  this  learning  has  been 
undertaken and no action has been taken by their employer WMAS and no restrictions or 
sanctions placed on their practice nor further individual training provided by WMAS and 
they continue in their respective roles. I am concerned this presents a clear existing risk 
to patients which remained unaddressed at the time of inquest.  

Response  
Following the clinicians attending to 
, they were both asked to provide documented 
reflective practice. The Trust can confirm these have been completed by both clinicians. 

Technicians  and  student  paramedics  always  work  with  a  fully  qualified  registered 
paramedic.  

Page 8 of 10 

 
 
 
 
 
 
 
 
 
 
   
 
 Both clinicians will be attending training school on 1 December 2023 for remedial training. 

Concern 12 
I  was  told  in  evidence  that  neither  paramedic  nor  technician  had  been  referred  to  the 
HCPC. I have reported my concern about the fitness to practice of both 

 to the HCPC however there appears to be a lacuna in respect of 

. 
  is  a technician  and not  a  fully  qualified  paramedic  and  as such  is  not  yet 
registered with the HCPC. Therefore, the HCPC can take no action at the present time. I 
am  informed  the  report  I  have  made  will  be  considered  at  such  time  as 
applies  for  full  registration.  I  am  concerned  this  presents  a  risk  to  patient  safety  at  this 
time.  

Response  
The Trust follows the guidance provided by the HCPC in relation to circumstances in which 
a  referral  by  an  employer  should  be  made.  This  guidance  can  be  found  on  the  HCPC 
website 
(https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-
us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was 
required  following  the  serious  incident  investigation.  Accepting  that  a  referral  has  now 
been made, the Trust will review its practices to ensure appropriate referrals are made.  

Concern 13 
 is a Student Paramedic (qualified/trained to technician 
I am informed that as 
level),  WMAS  as  her  employer  are  responsible  for  her  professional  competency.  I  am 
concerned that the lacuna I have identified in relation to her technician status has not been 
addressed and that despite WMAS applying the same HCPC standards to trainees as fully 
 fitness 
qualified paramedics, that WMAS have taken no action in relation to 
to practice and provided no further training. I am concerned this presents a risk to patient 
safety at this time.  

Response  
WMAS are responsible for the professional competency of our Student Paramedics. All 
technicians  and  student  paramedics  always  work  with  a  fully  qualified  registered 
paramedic. WMAS is the only ambulance service in the country to have a fully qualified 
registered  paramedic  on  every  emergency  ambulance.  A  paramedic  working  with  a 
student  paramedic  is  responsible  for  scene  management  and  clinical  decision  making. 
 will 
 will be attending training school on the 1 December 2023. 

also be attending training school on the same date. 

Concern 14 
I am concerned that there has been no collective learning by West Midlands Ambulance 
Service  following  the  death  of  Lauren  Smith.  There  has  been  no  action  to  address  the 
learning gaps identified by WMAS own internal investigation report in respect of both the 
paramedic  and  technician.  Therefore,  I  have  addressed  this  aspect  of  my  PFD  to  the 
CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the 
West  Midlands  Ambulance  Service  considering  the  risk  I  have  identified  in  relation  to 
patient safety due to inaction by WMAS.  

Page 9 of 10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response  
The Trust takes patient safety and the education and training of our staff very seriously.  

The Trust has undertaken a significant programme of work, which is ongoing, in relation 
to clinical improvement in the management of chest pain, ECG recognition and cardiac 
arrest management, evidence of can be found within concern 6. 

Once  the  Trust  became  aware  of  this  incident,  the  clinicians  involved  received  a  case 
review  with  a  CTM  on  3  February  2023  to  discuss  learning  points  and  reflect  on  the 
incident. The clinicians were also part of the Serious incident process and attended a  root 
cause  analysis  meeting  on  7  March  2023  where  the  case  was  discussed  in  detail. 
Following  the  Serious  Incident  investigation  both  staff  members  were  also  asked  to 
undertake  reflective  practice,  which  has  been  completed.  Additional  training  specific  to 
ECGs and ACS is scheduled to be completed on 1 December 2023. Both clinicians also 
received a clinical supervision shift. 
 completed this shift on 26 July 2023 
(Appendix 16) and 

 completed her shift on 11 July 2023 (Appendix 17). 
 also completed a CTM update day on 17 March 2023 due to her mentor role. 

I hope this response provides you with the appropriate level of assurance that as a Trust 
we have dealt with the concerns highlighted within your report and the extent to which we 
take patient safety very seriously.  

May I once again please pass on my sincere condolences to the family of Ms Smith. I am 
sorry we let Lauren down, and we let her family down.  

If you require any further assistance, please do not hesitate contact me. 

Yours sincerely, 

Chief Executive Officer 

Page 10 of 10