Sophie Wilson

Strictly Private and Confidential  
Ms Janine Richards 
His Majesty's Assistant Coroner for County Durham  
and Darlington 
H.M. Coroner’s Office 
P.O. Box 282 
Bishop Auckland 
Co. Durham 
DL14 4FY 

Date: 11th October 2024 

Dear Ms Richards, 

Inquest into the death of Sophie Jayne Wilson  

Regulation 28 – Report to prevent future deaths  

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

Tel: 0191 430 2000 
www.neas.nhs.uk 

Ref: 

I  am  writing  in  my  role  as  Chief  Executive  of  North  East  Ambulance  Service  NHS 
Foundation Trust ("NEAS") in response to the Regulation 28 report for the prevention of 
future deaths dated 2nd August 2024 as issued by you following the inquest into the tragic 
death of Sophie Jayne Wilson. I am sorry that you have had to raise concerns with NEAS 
following the inquest and would like to take this opportunity to pass my sincere condolences 
to the family of Sophie. 

The matters of concern listed in your report are: - 

1.  Although  I  received  reassurance  following  the  internal  investigation  that  actions 
have been completed and lessons learnt in relation to this death, I remain concerned 
about the fact that the ambulance crew and paramedic were entirely unaware of the 
familiar  faces  plan  in  place  for  Sophie  which  contained  crucially  important 
information pertinent as to how best to assist her, secure her engagement and in 
relation to issues of both capacity and risk. I was told in evidence that the difficulty 
related  to  a  data  limit  upon  the  electronic  devices  utilised  by  NEAS,  and  that 
therefore there should be a flag on electronic communications and that the control 
room would need to be contacted to obtain the additional information. NEAS were 
a signatory to the multi-agency familiar face plan in this case which applies to them 
as well as a number of other agencies and was designed to assist in supporting the 
deceased and to reduce the risk of harm. 

2.  I  am  concerned  that  the  information  was  not  seen  by  the  ambulance  crew  and 
paramedic  who  attended,  and  I  am  not  reassured  that  it  will  be  available  to  first 
responders on future occasions as it seems that the limits of the technology require 
the ambulance crew or paramedic to spot the flag and to contact the control room, 
presumably for a verbal account of the information only. I am concerned that in an 
emergency  situation  and  when  services  are  under  such  pressure  that  crucial 
information,  such  as  a  multi-agency  familiar  face  plan  is  not  easily  accessible  to 
those  attempting  to  offer  assistance  to  some  of  the  most  vulnerable  people  in 
society. 

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

1.  Although  I  received  reassurance  following  the  internal  investigation  that 
actions  have  been  completed  and  lessons  learnt  in  relation  to  this  death,  I 
remain concerned about the fact that the ambulance crew and paramedic were 
entirely unaware of the familiar faces plan in place for Sophie which contained 
crucially important information pertinent as to how best to assist her, secure 
her engagement and in relation to issues of both capacity and risk. I was told 
in  evidence  that  the  difficulty  related  to  a  data  limit  upon  the  electronic 
devices  utilised  by  NEAS,  and  that  therefore  there  should  be  a  flag  on 
electronic  communications  and  that  the  control  room  would  need  to  be 
contacted to obtain the additional information. NEAS were a signatory to the 
multi-agency familiar face plan in this case which applies to them as well as a 
number  of  other  agencies  and  was  designed  to  assist  in  supporting  the 
deceased and to reduce the risk of harm. 

I  believe  it  may  be  helpful  to  explain  the  electronic  devices  referred  to  in  the 
evidence provided during the inquest. In the first instance I understand the witness 
was  describing  the  Mobile  Data  Terminal  (MDT)  which  are  installed  in  double 
crewed  emergency  ambulances  and  emergency  rapid  response  vehicles.  These 
terminals,  commonly referred to  as  Terrafix,  are  secured  and hard  wired  into  the 
vehicles  in  line  with  Road  Vehicle  (Construction  and  Use)  Regulations  1986  and 
provide  ambulance  crews  with  satellite  mapping/navigation  to  the  scene  of  the 
emergency call alongside basic functions which track arrival/departure of the vehicle 
at scene and one way messaging from our Emergency Operations Centre (EOC). 
The latter one-way communication is a “flag” which presents messages on the MDT 
screen showing basic information to our staff while they are enroute to the incident.  

The  second  relevant  electronic  device  is  an  iPad  which  is  used  to  access  the 
electronic Patient Care Record (ePCR) which is the clinical record system used by 
emergency ambulance crews to document their contact with patient(s) as well as 
accessing  other  NHS  systems  to  obtain  additional patient  information.  The  iPads 
used  by  emergency  ambulance  crews  are  now  personal  issue,  following  a 
successful trial,  with the rollout of these devices commencing in August 2024, prior 
to this date the iPad (or previous electronic device) was part of the standard vehicle 
equipment.  Personal  issue  iPads  are  aimed  at  improving  and  supporting  the 
following areas: 

▪  Colleagues feel more valued and are more able to keep informed with the 

organisation 
Improve access to information and communication 

▪ 
▪  A reduction in downtime  
▪  Streamlined  recording  of  drug,  Infection  Prevention  Control  IPC)  and 
electronic Vehicle Daily Inspection (eVDI) audits and completion rates 

▪  A reduction in maintenance costs    

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

 
 
 
 
 
 
 
 
 In respect to the MDT, we have now confirmed with our suppliers that the character 
limits  on  individual  messages  to  the  MDT  are  1000  characters,  this  will  however 
increase to 3000 characters as a part of an ongoing upgrade of the current software 
and hardware which is estimated to be complete by February 2025. This upgrade is 
part  of  a  national  programme,  Emergency  Services  Network  (ESN).  The  Home 
Office is leading this cross-government programme to deliver the ESN which is a 
critical communications system  including multiple strands including hardware and 
software  upgrades.  This  will  replace  the  current  Airwave  service  used  by  the 
emergency services in Great Britain (England, Wales and Scotland) and transform 
how we operate. 

Whilst  we  are  confident  that  this  covers  messaging  requirements,  an  additional 
technical  control  will  be  introduced  to  split  any  messages  into  continuation 
messages should any exceed the specified character limit. In considering the above 
explanation the MDT within the vehicle is not suitable or an appropriate device to 
receive  documents  and/or for  crews to  use  this for reading  documentation, given 
the limitations even with the upgraded technology and software. The MDT serves a 
specific  purpose  which  is  predominately  for  satellite  mapping/navigation  and 
sending  critical  alerts  to  staff.  We  will  go  onto  explain  the  rationale  and  our 
alternative  solution  to  ensure  staff  have  access  to  additional  clinical  records  and 
information directly in the response to the second concern.  

2.  I am concerned that the information was not seen by the ambulance crew and 
paramedic  who  attended,  and I  am  not  reassured that  it  will be  available  to 
first  responders  on  future  occasions  as  it  seems  that  the  limits  of  the 
technology require the ambulance crew or paramedic to spot the flag and to 
contact the control room, presumably for a verbal account of the information 
only. I am concerned that in an emergency situation and when services are 
under  such  pressure  that  information,  such  as  a  multi-agency  familiar  face 
plan is not easily accessible to those attempting to offer assistance to some 
of the most vulnerable people in society. 

Linking  into  the  response  relating  to  the  first  concern,  we  are  progressing  with 
several  changes  to  improve  how  our  ambulance  crews  access  additional 
information. This includes some medium-term specific developments targeted at the 
previously mentioned NEAS electronic Patient Care Record system (ePCR) which 
emergency ambulance crews use, via the iPad, to access and record patient details, 
observations, and interventions. I will go onto explain the internal work and the wider 
system work with partners. Whilst some of these changes are within our own gift to 
implement  some  will  require  development  work  with  partners  and  link  in  with  the 
ESN programme briefly touched upon.  

In considering the fact the ambulance crew were unaware of the familiar faces plan 
in this case, in respect to terminology we would classify a familiar faces plan within 
the wider context of a special patient note or a flag. As an interim solution we have 
instructed our ambulance dispatch teams to verbally notify staff of any ‘flags’ placed 
against each case. This will enable an interaction and to seek an acknowledgement 
that ambulance crews have seen the ‘flag’ whilst providing an opportunity to share 
any additional information depending upon the type of ‘flag’.  

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

  
 
 
 It is however important to note that in times of extreme pressure our dispatch staff 
may  not  always  be  able make  this contact, whilst  balancing  other priority  contact 
with crews.  

I  acknowledge  that  this  interim  solution  is  not  permanent  but  provides  some 
additional controls to check that ambulance crews are aware of flags and associated 
information. I am sure you will appreciate that some ‘flags’ are very short such as 
an entry code for a key safe ranging up to those with a complex care plan shared 
by other organisations. In the latter we currently still rely upon this information being 
passed verbally to the attending crew. We will go onto explain the work we have 
commenced to improve this position and enable ambulance crews to directly access 
the information linked with any ‘flags’ such as care plans and or direct ambulance 
crews to other systems. 

To progress the medium-term improvement work, we have created an internal task 
and finish group who are tasked with assessing the current process and exploring 
options  to  improve  the  systems  and  process  relating  to  ‘special  patient  notes’  or 
simply ‘flags’ and the ability of ambulance crews to directly access this information. 
I can confirm that the group held the first meeting on 1 st October 2024 with further 
meetings  being  scheduled  to  progress  with  the  outputs  from  the  group.  It  is 
important to note that other workstreams are linked  with the task and finish group 
which will help triangulate the wider system improvements I have described.   

Linked  with  these  medium-term  developments  we  have  already  commenced 
consultation with our software supplier  in respect to the feasibility and timescales 
associated  with  this  development.  Initial  engagement  has  been  positive,  and  we 
have obtained a quote to undertake the technical development  work, and a quote 
has now been obtained with funding identified internally. The changes are currently 
being  considered  via  internal  governance  routes  to  assess  potential  risks  and 
provide  assurances  in  respect  to  the  impact  of  the  proposed  changes.  Once  the 
NEAS  subject  matter  expert  groups,  Change  Approval  Board  and  Operational 
Management Group, have granted approval the Executive Management Group will 
consider  the  combined  expert  opinions  and  approve  the  changes.    Once  the 
proposed  developments  have  been  assessed  and  approved,  we  estimate  the 
development,  testing,  training,  will  take  approximately  4-6  months  to  safely  and 
effectively implement. This work will allow special patient notes and/or flags to sent 
directly to the iPads enabling crews to directly access the special patient note/flag 
linked with the specific  patient and not reply upon the passage of information via 
radio or telephone from the Emergency Operations Centre (EOC).  

Whilst the proposed improvement is being progressed, NEAS will continue to hold 
manually maintained flags and care plans (where these have been made available 
to  the  Trust)  and  re-circulate  current  procedures  and  the  importance  of  staff  to 
review where relevant information may be available (including GP Connect / Great 
North Care Record where flagged) and contact the Emergency Operations Centre 
(EOC)  if  further  details  are  required  (especially  when  dealing  with  mental  health 
related cases). As part of the ongoing work our Special Patient Notes (SPN) team 
will  continue  to  oversee  and  review  flags  and  related  care  plans,  including  the 
duration and signoff of care plans and any associated information.  

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

 
 
 
 
 The existing process includes the involvement of other relevant internal and external 
specialists,  as  appropriate,  to  ensure  flags  and  care  plans  are  appropriate  and 
correct. This process will be reviewed and updated as part of the medium-term work 
being undertaken by the task and finish group. 

During  our  review  we  have  also  considered  the  associated  guidance  from  the 
Association  of  Ambulance  Chief  Executives  (AACE),  specifically  the  publication 
relating  to  ‘red  flagging’  of  patients  with  specific  clinical  conditions.  Whilst  we 
recognise and share the concerns around the additional workload in respect to the   
maintenance of flags and care plan management placed on NEAS, we believe that 
until  an  automated  regional  based  solution  can  be  provided,  we  will  continue  to 
accept care plans and flags from our  partners, in the interest of aiding our crews 
with the delivery of patient care.  

It was helpful to note that the Independent Review of the NHS undertaken by Lord 
Darzi has also identified concerns with the shortfall of capital investment, citing the 
“on top of that, there is a shortfall of £37 billion of capital investment. These missing 
billions are what would have been invested if the NHS had matched peer countries’ 
levels  of  capital  investment  in  the  2010s.  That  sum  could  have  prevented  the 
backlog maintenance, modernised technology and equipment, and paid for the 40 
new hospitals that were promised but which have yet to materialise. It could have 
rebuilt or refurbished every GP practice in the country”.. It is hoped that report will 
aid  the  wider  NHS  to  work  collaboratively  to  drive  forward  the  reform  and 
realignment to improve productivity by moving the care closer to home.  

Linked with the above, our records show that the  majority of care plans and flags 
are  created  by  our  wider  system  partners,  a  North  East  and  North  Cumbria 
Integrated Care Board (ICB) wide group has been established and is now meeting 
regularly  to  improve  the  flagging  challenges  and  a  coordinated  approach  to 
standardise  and  centralise  the  production,  storage,  and  access  to  care  plans  for 
consideration by the North East and North Cumbria ICB Digital Board. 

In  respect  to  access  to other  clinical records,  NEAS  ambulance  crews  also  have 
access to the GP summary information (via GP Connect) and the Great North Care 
Record, which is a region wide shared care record providing information associated 
with patients from all providers in the region. Linked with my response to your first 
concern, I have explained that we have instructed our ambulance dispatch teams to 
verbally notify staff of any ‘flags’ placed against each case. Alongside this process 
we will be cascading information to emergency ambulance crews in respect to the 
importance of accessing additional information and using the appropriate systems. 

It is important to mention that both information sharing platforms, GP Connect and 
Great  North  Care  Record,  do  not  presently  have  full  patient  details  or  care  plan 
documents from all providers.  The North East and North Cumbria Integrated Care 
Board is leading on a ‘levelling up’ project for all providers in our region. NEAS will 
continue to work with wider system partners to develop more effective centralised 
means of region wide flagging and care plan sharing. 

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

 
 
 
 
 
 
 
 I hope this response provides you and the family with the appropriate level of assurance 
that as a Trust we are dealing with the concerns highlighted within your report. I appreciate 
that  it  may  be  difficult  to  appreciate  the  technologies/systems  used  by  NEAS  especially 
without the benefit of visualising the devices and how they work. If it would be helpful, we 
would  gladly arrange  a  visit  to  our  Emergency  Operations  Centre  to  show you  how the 
technology works in operational use as well as how ambulance crews use the MDT and 
ePCR. May I once again pass on my sincere condolences to the family of Sophie.  If we 
can  be  of  any  further  assistance  then  please  do  not  hesitate  to  contact 
, 
Head  of  Regulatory  Services  via  email  at 
  or  telephone 
07891 469571.  

Yours sincerely,  

Chief Executive 

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