Mark Bennett

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

14 November 2023 

BY EMAIL:   

Mr Steve Eccelston  
Assistant Coroner for South Yorkshire (West)  

Dear Mr Eccelston 

MARK BENNETT (DECEASED)  

I am writing in response to the preventing future deaths report we received at the Association of 
Ambulance Chief Executives (AACE) dated 19th September 2023, and I respond as the Director of 
Operational Development and Quality Improvement on behalf of the AACE.   

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh 
Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, 
co-ordinates and implements nationally agreed policy.  Our primary focus is the ongoing development of 
the English ambulance services and the improvement of patient care.  It is a company owned by NHS 
organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison 
Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not 
constituted to mandate or instruct ambulance services however it has national influence via the regular 
meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-
groups.  

With regard to your matter of concern relating to ambulance services and resuscitation: 

Lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or 
ambulance staff which might place future patients at risk in similar situations. In particular, how long should 
resuscitation continue for and when should a patient be taken to hospital for thrombolysis.  

With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”).  The 
JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the 
assessment and management of a wide range of clinical presentations.  The guidelines have specific 
sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned 
to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE.  One 
particularly guideline  is called: Termination of Resuscitation and Verification of Death in Adults. It contains 
guidance on those conditions that are unequivocally associated death, and other conditions where 
resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the 
decision to terminate resuscitation was increased from 20 minutes to 30 minutes. The guidance currently 
contains specific wording in relation to pulseless electrical activity: 

Young age, myocardial infarction and potentially reversible causes of cardiac arrest, such as hypothermia 
and pulmonary emboli, are associated with a better outcome, especially when the arrest is witnessed and 
followed by prompt and effective resuscitative efforts. 

Within the advanced life support guidance there is a section of guidance on reversible causes and 
specialist circumstances in cardiac arrest - commonly known as the  4Hs and 4Ts. One of the reversible 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 causes to consider is that the patient may have a coronary or pulmonary thrombosis. The current wording 
states: 

Thrombosis-Coronary or Pulmonary 
Pulmonary 
This will be challenging to diagnose in the cardiac arrest situation. If available, the 
patient’s history before cardiac arrest may give some indication. If pulmonary thrombosis 
is suspected, a time-critical transfer to hospital is indicated. In situations where 
thrombolysis is administered, CPR for as long as 90 mins may be required to break up 
the clot. In these circumstances, consider mechanical CPR. 
Intra-arrest thrombolysis can be considered if available: follow local pathways but do not 
delay conveyance to hospital. 

AACE are not responsible for the training or education of ambulance staff, however we are aware that 
ambulance trusts have a responsibility to ensure that staff that attend cardiac arrests are adequately 
trained and that this training is regularly updated.  

The JRCALC guidelines are produced to assist UK Paramedics undertake their role effectively.  We 
appreciate that our clinicians have to make difficult decisions around resuscitation practice, especially in 
relation to when to commence and when to terminate resuscitation. Many factors need to be taken into 
account, often rapidly and during stressful situations.  We are continually reviewing and updating all our 
guidance on a regular basis and when new evidence becomes available.  

We are supportive and engaged with a current and ongoing National Institute for Health Research  
funded study titled:  Exploring and improving resuscitation decisions in out of hospital cardiac arrest.  
The study aims to  determine what is the best approach for deciding when and where to stop resuscitation 
attempts. Presentation of research findings to a stakeholder group took place on 18th October 23 of which 
a number of AACE representatives attended. The output from this research will be an evidence informed, 
ethically grounded, termination of resuscitation guideline, which is acceptable to NHS staff, patients and 
their relatives. Subject to relevant approval processes, we anticipate that the results of this study may lead 
to an update to our JRCALC guidance leading to better decisions for patients and their relatives. 

On behalf of AACE, I would like to extend our sincere condolences to the family of Mark Bennett. 

I hope this response has adequately addressed the concerns that you have raised.  If you have any further 
questions please do not hesitate to get in touch.  

Yours sincerely 

Director of Operational Development and Quality Improvement

Mr S Eccleston 
HM Assistant Coroner for South Yorkshire (West) 
The Medico- Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

Springhill 2 
 Brindley Way 
Wakefield 41 Business Park 
Wakefield  
WF2 0XQ  

2 November 2023 

Dear Sir 

Re: Inquest touching the death of Mark Bennett 

I write on behalf of Yorkshire Ambulance Service NHS Trust (YAS) and in response to the 
Regulation 28 report on this matter, issued on 26 September 2023 and received by 
Yorkshire Ambulance Service NHS Trust (YAS) on 23 October. 2023.  

I am aware of the circumstances of Mr Bennett’s tragic death and take this opportunity to 
offer my sincere condolences. 

Your matter of concern was: “I believe there is a lack of guidance and/or protocols on what 
constitutes best practice on this issue for paramedics and/or ambulance staff which might 
place future patients at risk in similar situations. In particular, how long should resuscitation 
continue for and when should the patient be taken to hospital for thrombolysis.”  I 
understand this relates to the clinical management of a patient in cardiac arrest who has a 
suspected pulmonary thromboembolism (PE). 

Nationally, ambulance clinicians follow standard clinical practice guidelines developed and 
managed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) on behalf 
of the Association of Ambulance Chief Executives (AACE). These are universally referred 
to as the JRCALC Guidelines. Guidelines relating to the management of cardiac arrest 
follow the Resuscitation Council (UK) guidelines. The guidelines are clear on the delivery 
of Advanced Life Support (ALS) and when to consider that to commence or continue 
resuscitation attempts would be futile. YAS clinicians have the ability at all times to access 
these guidelines via an app on a personal issue YAS mobile phone. 

www.yas.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In this instance the potential cause of cardiac arrest being a PE was recognised by the 
attending paramedic. PE is one of the potentially reversible causes of cardiac arrest 
described in the JRCALC guidelines. ALS requires exclusion or treatment of a potentially 
reversible cause before resuscitation attempts should cease. If appropriate treatment 
cannot be provided in the pre-hospital environment, then the patient should be conveyed to 
the nearest Emergency Department, with cardiopulmonary resuscitation (CPR) ongoing, 
without delay. 

Paramedics are also supported to make decisions about the futility of commencing or 
continuing resuscitation attempts and JRCALC provides clear guidance on the scope in 
which paramedics may make these difficult decisions. Unfortunately, in this instance, but 
clearly with the best of intentions, a decision was made which falls outside that scope. On 
review, YAS documentation could be more supportive in making these decisions. To that 
end, I have asked that the clinical documentation is reviewed and updated, and decisions 
relating to the termination of resuscitation attempts are covered as a component of annual 
clinical refresher training. 

My thoughts remain with Mr Bennett’s family. 

Yours faithfully 

Chief Executive