Emily Stokes

Report in Response to Coroner’s 
Regulation 28 Report – Matters of 
Concern 

Date: 7th July 2025 
Prepared by: 
Organisation: Kent Central Ambulance Service 

, Facilities and Compliance Lead 

Introduction 

This report is prepared in response to the concerns raised under Regulation 28 following 
the inquest into the death of  Emily Rose Stokes from MDMA Toxicity. Emily had made 
plans to meet friends at the Worried about Henry at Dreamlands music festival in Margate, 
on the 29th of June 2024. 

The findings of the coroner have been taken with the utmost seriousness. As a healthcare 
provider, Kent Central Ambulance Service is committed to continuous learning, service 
improvement, and ensuring the highest standards of patient safety, comfort and care. 

This  document  outlines  the  specific  concerns  raised  by  the  coroner  and  details  of  the 
actions taken and planned by Kent Central Ambulance Service to address these concerns 
and implement robust corrective measures. 

Summary of Matters of Concern 

The coroner raised the following key issues: 

1.  Training  and suitability  of  ambulance  staff –  Concerns  about  the  ambulance 
crew that attended the event were minimally trained and not equipped to manage 
high-risk environments involving possible drug use. 

2.  Clarity  of  responsibility  for  pre-alerting  the  hospital –  Ambiguity  regarding 
whether  the  responsibility  to  pre-alert  the  receiving  hospital  lay  with  the 
paramedics or the private ambulance crew. 

3.  Adequacy of ambulance equipment – The vehicle used was not considered to 

be fully equipped in comparison to NHS ambulances. 

Kent Central Ambulance 

1 

 
 
 
 
 
 
 Kent  Central  Ambulance  provide  Non-Emergency  patient  transport  for  Maidstone  & 
Tunbridge Wells NHS Trust. The nature of the work includes the transportation of patients 
requiring transport to or from a trust site to other hospitals, nursing homes, hospices and 
any other location as determined by the Trust. We also cover event around the Kent & 
Medway Region.  
Our  service  provisions  for  NEPTS  will  include  High  Dependency,  Bariatric  patient, 
Stretcher  and  Wheelchair  patient  transfers.  Our  ambulance  crew  responsibilities  will 
include but are not limited to: 

In safe and timely manner in a vehicle appropriate to their needs, 

•  Ensure that patients are transported in the following way 
• 
•  They are collected promptly, in reasonable timescales,  
•  They are treated with courtesy, dignity, and respect at all times 
•  There  will  be  no  detriment  to  the  patient’s  health  and  wellbeing  during  their 

journey. 

Our Staff Training & Skill Set 

Our  training  protocols  encompass  two  distinct  formats:  online  modules  and  in-person 
classroom sessions.  The training program has been developed to ensure staff members 
can develop in a supportive environment and undertake courses that will improve their 
capabilities  and  improve  patient  care.  Taking  into  consideration  other  qualifications 
gained, previous experience, the needs and demands of the business.   

We also provide Clinical Helpline support via our partnership with BEARS ambulance 
service, this is an immediate helpline for our ambulance crews in the event they encounter 
and  challenging  situation,  for  immediate  guidance  and  support  in  the  event  they  need 
support following a traumatic experience. 

At KCAS, the grade of staff undertaking High dependency (HD) journeys or transporting 
service users in an emergency would be. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ambulance Care Attendant (ACA) – First Responder Emergency Care Level 3, with 
medical escort and the patient has been risk assessed by a clinician at the discharging 
hospital. 

Clinical 
Role: 

Ambulanc
e Care 
Assistant 
(ACA) 

Scope of Practice: 

Intended case load: 

FPOS(i) or FREC 3 
Oxygen and Entonox Therapy 
PTS and Blue Light 
Emergency Driving Cardiac 
Monitoring (3 lead ECG) 
Basic Rhythm Recognition 
LifePak 12/15 Automated 
Defibrillation 
Oropharyngeal/Nasopharyngeal 
Airways Suction (Handheld/Laerdal 
Suction Unit) Recognition of 
Tracheostomy Emergencies BLS, 
PBLS & BVM 
Manual 
Handling 
Bariatric 
Handling 
MIBS 
Stretcher 
Safeguarding 
Referrals 
Tourniquet for Cat. Haemorrhage 

Selected experienced ACAs to act 
as mentors and sponsors for new 
recruits to assist in the signing off 
for: 

•  Shadowing 
•  Practical use of Equipment 
•  Safe Systems of Working 

All staff are required to complete the 
Online Training as detailed attached 

Patient Transport/Non- emergency 
journeys. 
Risk Assessed High Dependency 
Journeys not requiring a Paramedic, and 
as below: 

•  High Dependency Journeys 
with a Medical escort. 

•  Running Calls. 
•  Bariatric Patients. 
• 

Informal MH Patients. 

High Dependency Journeys are defined in 
contract as: 

•  Stroke patient being transferred 
for immediate or emergency 
treatment. 

•  Suffering from continuous 

epistaxis requiring treatment or 
surgery. 

•  Patients with quinsy post 

treatment to secondary facility. 

•  Sickle Cell patient, hypoxic or 

requiring Oxygen. 
•  Tracheostomy in situ. 
•  Level 1 and 2 Critical care 

Patients. 

•  End of Life or Palliative care 

patient. 

•  Patients >5l Oxygen required. 
•  Patients requiring Suctioning, 
Entonox, Observations inc. 
cardiac monitoring. 

•  Blue light transfer authorised by 

Doctor or Senior Nurse. 
•  Paediatric Pt requiring Pedi- 
mate, Pod (or Incubator with 
Medical Escort). 

•  Patients with locked off/disabled 

syringe drivers or pumps. 

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 Emergency Care Attendant – First Responder Emergency Care Level 4 (FREC4) with 
medical escort and the patient has been risk assessed by a clinician at the discharging 
hospital. 

Clinical 
Role: 

Emergency 
Care 
Assistant 
(ECA) 

Scope of Practice: 

Intended case load: 

FPOS(e) or FREC 4 
Oxygen and Entonox Therapy 
Blue Light Emergency Driving 
Cardiac Monitoring (3 lead ECG) 
Basic Rhythm Recognition 
LifePak 12/15 Automated 
Defibrillation 
Oropharyngeal/Nasopharyngeal 
Airways 
Suction (Handheld/Laerdal Suction 
Unit) 
Recognition of Tracheostomy 
Emergencies 
BLS, PBLS & BVM 
Manual Handling 
Bariatric Handling 
MIBS Stretcher 
Safeguarding 
Referrals 
Tourniquet for Cat. Haemorrhage 

Selected experienced ECAs to act 
as mentors and sponsors for new 
recruits to assist in the signing off 
for: 

Shadowing 
Practical use of Equipment 
Safe Systems of Working 

All staff are required to complete the 
Online Training as detailed attached: 

Patient Transport/Non-emergency 
journeys. 
Risk Assessed High Dependency 
Journeys not requiring a Paramedic, 
and as below: 

•  High Dependency Journeys 
with a Medical escort. 

•  Running Calls. 
•  Bariatric Patients. 
• 

Informal MH Patients. 

High Dependency Journeys are 
defined in contract as: 

•  Stroke patient being 

transferred for immediate or 
emergency treatment. 
•  Suffering from continuous 

epistaxis requiring treatment or 
surgery. 

•  Sickle Cell patient, hypoxic or 

requiring Oxygen. 
•  Tracheostomy in situ. 
•  Level 1& 2 Critical care 

Patients. 

•  End of Life or Palliative care 

patient. 

•  Patients >5l Oxygen required. 
•  Patients requiring Suctioning, 
Entonox, Observations inc. 
Cardiac monitoring. 

•  Blue light transfer authorised 
by Doctor or Senior Nurse. 

•  Paediatric Pt requiring Pedi- 
mate, Pod (or Incubator with 
Medical Escort). 
•  Patients with locked 

off/disabled syringe drivers or 
pumps. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Online training for all staff  includes Fire safety; Health and Safety; Infection Prevention 
and  Control;  Dementia;  Mental  Capacity  Act  and  DOLS;  Safeguarding  Adults; 
Safeguarding Children; Moving and Handling People; Conflict Management & Resolution; 
Data Protection; Counter fraud in the NHS.   

Response to Identified Concerns 

1.   Staff Training and Preparedness for High-Risk Events 

We confirm that the staff deployed on the day were trained and certified according to their 
roles. However, on reflection, we recognise that deployment of our staff to events where 
there  was  an  increased  likelihood  of  young  persons  in  attendance  coupled  with  the 
potential for illicit substance use, required a higher level of specific and scenario-based 
training.   

Actions Taken: 

An evaluation of previous approach to accepting events coverage has been completed 
and as part of our learning we have put in pace the following: 

Process Step Change: 

For all event coverage booking request:  

a.  Clarity and engagement with the Event Management team to scope the 

requirement, support on the day, number of spectators, age group and type of 
event 

b.  We evaluate our suitability for the service; this exercise is conducted by our 
senior management team with the support of the clinical lead to scope and 
confirm that our resource capability for the service requirement. 

c.  We complete a risk matrix to understand likely /unlikely risk during event and 

match this to our scope of practice. 

d.  A team of experienced staff is then established to cover public events, depending 
on the following groupings: especially those involving young persons or known 
drug-risk environments. 

•  These staff will receive enhanced training, covering: 

o  Recognition of drug and alcohol intoxication 
o  Clinical red flags and deterioration signs 
o  Communication and escalation protocols 
o  Situational awareness and de-escalation 
o  Responding to medical emergencies in dynamic settings 

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 2.   Clinical Decision-Making and Pre-Alert Protocol 

On the day of the incident, the attending crew identified concerns and sought to escalate 
via a hospital pre-alert. However, direction was given by on-site paramedics that a pre-
alert  was  not  required,  and  transport  was  conducted  without  blue  lights  or alerting  the 
hospital in advance. 

Action Taken: 

•  We have clarified our internal clinical escalation protocol, which now mandates 

that: 
o 

If a crew has any concern, they must escalate via the Clinical Support 
Line, regardless of other clinician directions. 

o  Crews are now explicitly empowered to pre-alert independently if in doubt. 

•  All crews will receive refresher training on pre-alert criteria and documentation, 

with emphasis on patient safety as the guiding principle. 

3.   Vehicle Equipment and Suitability 

The vehicle used was a High Dependency Vehicle (HDV) and was staffed by a crew of 
two staff members. The vehicle was equipped with monitoring equipment, oxygen, 
resuscitation tools, and all other kit deemed appropriate for the level of care authorised 
under their scope. 

Action Taken: 

•  We have implemented a pre-event vehicle checklist to ensure uniformity and 

accountability in equipment preparation. 

•  A clinical inventory standard is being developed and benchmarked against NHS 

specifications to ensure parity wherever possible. 

Organisational Enhancements and Forward Planning 

1.   Creation of a Dedicated Event Staff Team 

•  A team of experienced and specially trained staff will form a core group for 

event deployments. 

•  These staff will receive dedicated event medical training and annual 

refreshers. 

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 2.   Structured Pre-Event Briefings and Sign-Off 

On completion of our new step change process for Event Coverage, prior to any 
event, all staff attending will receive a formal briefing including: 

o  Event-specific risks 
o  Likely patient profiles 
o  Local and on-site escalation procedures 
o  Contact details for clinical support 

•  Each staff member will be required to sign off on their briefing to confirm 

understanding. 

3.   Mandatory Medical Operational Plans (MOPs) 

•  A comprehensive Medical Operational Plan (MOP) will now be created for 

each event. 

•  MOPs will include staffing, response structure, communication protocols, and 

escalation pathways. 

•  MOPs will be distributed to all relevant staff prior to deployment. 

4.   Enhanced Use of Clinical Support Line 

•  Staff will be re-trained on when and how to contact the Clinical Line. 
•  The Clinical Line will serve as a second opinion service, especially in cases of 

disagreement or clinical uncertainty. 

5.   Purple Guide Subscription and Integration 

•  The organisation has subscribed to the Purple Guide, an industry standard for 

health and safety at events. 

•  The guide will inform our risk assessment, staff deployment, and response 

framework for all future events. 

6.   Deployment of Event Readiness Checklist 

•  All crews will receive a new event checklist, covering: 

o  Essential equipment 
o  Key clinical signs to watch for 
o  Contact and escalation details 
o  Criteria for hospital pre-alert 
o  Documentation expectations 

7 

 
 
 
 Learning from the Incident 

This incident and the Coroner’s findings will be used as a formal case study for internal 
learning. Key learnings will be embedded in: 

•  Future staff induction 
•  Refresher training modules 
•  Governance and audit processes 
•  Pre-event operational reviews 

This event will also be included in our annual Clinical Governance Review and form 
part of wider quality improvement projects. 

Commitment to Ongoing Improvement 

We recognise the tragic nature of this incident and the need for continued service 
improvement. Our organisation is committed to: 

•  Ensuring staff readiness for all deployment environments 
•  Strengthening communication and escalation protocols 
•  Upholding a high standard of clinical responsibility and patient safety 

This  report  outlines  the  meaningful  steps  we  are  taking  to  respond  to  the  Coroner’s 
concerns  and 
further 
recommendations and welcome ongoing dialogue with relevant bodies. 

lasting  change.  We 

remain  open 

implement 

to  any 

Prepared by: 

Facilities and Compliance Lead 
Kent Central Ambulance Service 
7th July 2025 

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