Aran Bradbury

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

W: www.aace.org.uk

16 December 2024

BY EMAIL:

Christopher Leach
Assistant Coroner for Norfolk

Dear Mr Leach

ARAN SEAN BRADBURY (DECEASED)

I am writing in response to the preventing future deaths report I received at the Association of
Ambulance Chief Executives (AACE) and I respond as our Director of Operational Development and
Quality Improvement on behalf of AACE and the National Ambulance Service Medical Directors
(NASMeD).

On behalf of AACE and NASMeD, I would like to extend our sincere condolences to the family of Mr
Bradbury.

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh
NHS ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the
implementation of national agreed policy and to act as an interface, where appropriate at a national
level, between them and their stakeholders. It is a company owned by NHS organisations and
possesses 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 chairs along with a network of national
specialist sub-groups. One of the national sub groups is NASMeD. The medical directors of the
ambulance trusts meet around every six weeks, and their purpose is to improve clinical safety and
quality of care by reducing unwarranted variation, sharing best practice, leading clinical research
across the NHS ambulance services, overseeing the development of the JRCALC clinical practice
guidelines and support and receive information from other specialist subgroups. I have liaised with
the chair of NASMeD with regard to providing this response, and the PFD has also been shared with
NASMeD for awareness.

I note that this PFD report has been issued to us at AACE and NASMeD and also to the NHS
England Emergency Call Prioritisation Advisory Group (ECPAG).

In response to your matters of concern around 999 call categorisation, we must inform you that the
primary ownership of these matters lie with NHS England.  NHS England administer and chair the
Clinical Coding Review Group. Any changes to categorisation of calls proposed by this group are
then taken to NASMeD for endorsement and are then taken to ECPAG for approval. Once changes

 are approved by ECPAG they are issued to ambulance services to implement. We have liaised with
NHS England and are assured that the matters of concern are being considered.

If you have any further questions please do not hesitate to get in touch.

Yours sincerely

Director of Operational Development and Quality Improvement

Christopher Leach 
Assistant Coroner for Norfolk 
County Hall 
Martineau Lane 
Norwich 
NR1 2DH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

19th December 2024   

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Aran Sean Bradbury who 
died on 25 August 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  24 
October  2024  concerning  the  death  of  Aran  Sean  Bradbury  on  25  August  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Aran’s family and loved ones. NHS England are keen 
to assure the family and the Coroner that the concerns raised about Aran’s care have 
been listened to and reflected upon.   

In your Report you raised concerns regarding the coding of the 25-C code subsets, 
which  are  defined  by  the  Emergency  Call  Prioritisation  Advisory  Group  (ECPAG). 
Specifically,  you  raised  that  patients  with  a  history  of  mental  illness,  who  might 
otherwise  warrant  a  Category  2  ambulance  prioritisation,  could  be  prioritised  as 
Category 3 instead due to the system, resulting in a longer waiting time. NHS England 
has liaised with the Chair of the NHS England ECPAG to inform this response. 

Ambulance  Emergency  Operation  Centres  (EOCs)  use  one  of  two  approved  triage 
tools  to  code  999  emergency  calls  –  Advanced  Medical  Priority  Dispatch  Systems, 
(AMPDS) or NHS Pathways. 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 (Categories 1 – 5) set 
out  within  the  NHS  Constitution  and  Ambulance  Service  999  contracts.  Category  5 
(originally Category 4H) relates to calls that do not require an ambulance response; 
there is no standard for Category 5 calls.  

The  grading  of  999  calls  are  clinically  based  decisions  and  any  changes  are 
considered by the NHS England ECPAG, based on receipt of a review of the evidence 
base  with  formal  recommendations  from  the  NHS  England  Clinical  Coding  Review 
Group,  with  endorsement  of  the  clinical  rationale  of  proposed  changes  by  the 
Association  of  Ambulance  Chief  Executives’  National  Ambulance  Service  Medical 
Directors group (NASMeD). Any recommendations that are made and implemented 
will be formally reviewed with ongoing monitoring from ECPAG. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 There  are  over  1,700  AMPDS  dispositions  and  219  dispositions  used  in  NHS 
Pathways  for  999,  which  are  mapped  to  one  of  the  response  categories,  which 
individual ambulance services are required to comply with.  

The  mapping  of  a  patient  to  an  initial  response  category  is  only  the  first  step; 
ambulance  services  have  robust  clinical  oversight  safeguards  in  place  for  patients 
presenting with overdose and suicidal ideation. EOCs follow specific principles on their 
respective triage tool to ensure clinical oversight is rapidly initiated. These principles 
have  been  reviewed  and  strengthened  through  several  national  recommendations 
since 2019. 

Firstly,  on  2  April  2019, 
  –  the  then  National  Clinical 
Director for Urgent and Emergency Care at NHS England – wrote to ambulance trusts 
and NHS 111 providers to mandate that robust clinical oversight was in place in control 
rooms and call centres to monitor self-harm and suicidal patients safely and effectively. 

Secondly, in 2020, the then Healthcare Safety Investigation Branch (HSIB), now the 
Health  Services  Safety  Investigations  Body  (HSSIB),  investigated  the  potentially 
under-recognised  risk  of  harm  from  the  use  of  propranolol.  They  made  a  safety 
recommendation for NHS England to evaluate current approaches to clinical oversight 
of  overdose  calls  within  ambulance  control  rooms,  and  to  develop  a  national 
framework  to  describe  requirements  for  appropriate  clinical  oversight  of  overdose 
calls. 

NHS England issued internal guidance to ambulance services relating to overdoses 
and  suicidal  intent  in  April  2021.  The  guidance  highlights  the  critical  importance  of 
clinical oversight and review and sets out that: 

•  where a potential threat of suicide is declared, an urgent clinical review should 
take place within 30 minutes, or the case must be automatically upgraded to a 
Category 2 if this does not occur within 40 minutes. 
the initial clinical review should consider any ongoing suicidal ideation with a 
specific plan / means. 

• 

Most  recently,  the  overdose  guidance  was  updated  in  November  2023  to  include 
callers who reach a Category 5 disposition (hear and treat). This followed a review by 
ECPAG, NHS England and NASMeD to ensure it remained clinically fit for purpose. 

You raised concerns in your Report regarding the coding of the 25-C code subsets. 
The AMPDS sub-group of ECPAG has escalated the issue with the 25-C codes to the 
International  Academies  for  Emergency  Dispatch  for  rapid  resolution, to amend  the 
software used to triage calls through AMPDS. 

NHS  England’s  ECPAG  has  since  written  to  all  ambulance  trusts  asking  them  to 
confirm full compliance with all aspects of the NHSE guidance on ‘999 overdose and 
suicidal  ideation  calls’  and asking AMPDS  trusts  to  confirm  they  have  ensured  that 
any  calls  where  a  25-C-1  (any/no  suffix),  25-C-2  (any/no  suffix)  or  25-C-4  (any/no 
suffix)  determinant  is  reached,  are  amended  to  a  Category  2  if  there  is  use  of 
medications or substances, until a software update is implemented. 

 
 
 
 
 
 
 
 
 
 I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Aran, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director