Edie Smart

Ambulance Headquarters 

Bernicia House 

The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Strictly Private and Confidential 
Miss Georgina Nolan 
His Majesty’s Senior Coroner for Newcastle and North Tyneside 

Date: 31 July 2026 

Dear Miss Nolan, 

In the inquest touching on the death of Ms Edie Smart – Regulation 28 Response 

I  am  writing  in  my  role  as  Chief  Executive  of  North  East Ambulance  Service  NHS 
Foundation  Trust  (‘NEAS’)  and  in  response  to  the  Regulation  28  report  for  the 
prevention of future deaths dated 09 June 2026 as issued by you following the inquest 
into the tragic death of Ms Edie Grace Smart. I am sorry that you have had to raise 
concerns with NEAS following the inquest and would like to take this opportunity to 
pass on my sincere condolences to the family of Edie. 

This response will address the matters of concern raised in your Regulation 28 Report, 
as replicated below: 

1.  Ambulance  Support  Practitioners  are  often  first  on  scene  on  an  out  of 
hospital  cardiac  arrest  but  are  only  trained  to  use  i  gels  to  secure  a 
patient's airway under the supervision of a paramedic. 

Part (i) – Ambulance Support Practitioners (‘ASP’) Role 

The ASP role was introduced as part of a series of changes to NEAS’ workforce, which 
included  a  transition  away  from  the  Emergency  Care  Technician  and  Clinical  Care 
Assistant  roles.  The  purpose  of  such  transition  was  to  establish  a  trained  support 
workforce to operate within a paramedic-led model of care. 

ASPs  are  not  registered  healthcare  professionals  but  are  trained,  assessed,  and 
authorised to undertake a defined range of clinical interventions within an established 
scope  of  practice.  The  ASP  role  was  formally  implemented  across  NEAS  on  01 
November 2024. Since its introduction, all relevant non-registered clinical staff have 
undergone  a  process  of  scope-of-practice  realignment,  supported  by  additional 
education,  training,  and  competency  assessments,  to  ensure  that  they  are 

1 

 
 appropriately  prepared  to  practise  consistently  and  safely  within  the  defined  ASP 
scope of practice.  

Part (ii) – Deployment of ASPs 

NEAS’ deployment model is primarily based upon ASPs working alongside registered 
paramedics  in  a  supportive  capacity.  However,  at  any  given  time,  NEAS  does  also 
deploy,  on  average,  ten  non-paramedic-led  Double  Crewed  Ambulances  (‘DCA’) 
across the North East region. These resources are staffed by two ASPs and represent 
approximately 7% of the Trust's total available operational resources.  

The primary function of NEAS’ double-ASP ambulance crews is to provide transport 
for  patients  who  have  already  been  clinically  assessed  by  a  registered  healthcare 
professional. This includes appropriate inter-facility transfers, category 3 and 4 calls 
from  a  registered  healthcare  professional,  and  category  4  or  other  urgent  incidents 
where  a  working  impression  or  diagnosis  has  already  been  established,  and  the 
patient  has  been  confirmed  as  only  requiring  basic  monitoring  during  transport. 
Double-ASP ambulances are not intended to act as an ambulance resource capable 
of  independent  clinical  assessment,  and,  by  having  a  small  number  of  double-ASP 
ambulances available to transport patients who have already been clinically assessed 
and do not require ongoing clinical care, this allows for paramedic-led ambulances to 
be kept available for other 999 calls which require clinical assessment and care. 

There are however circumstances where deploying a double-ASP crew as the initial 
response to a category 1 (‘C1’) incident is both appropriate and in the patient’s best 
interests.  The  NEAS  deployment  plan  permits  a  non-paramedic-led  DCA  to  be 
deployed as the first response to a C1 incident where there is no closer paramedic 
response available, provided that the crew is immediately backed up by a paramedic 
resource. This approach enables the closest appropriate available resource to attend, 
in  order  to  provide  time-critical,  potentially  life-saving  basic  interventions,  including 
basic  airway  management,  assisted  ventilation,  cardiopulmonary  resuscitation,  and 
defibrillation. Per the deployment plan, it remains expected that a paramedic resource 
should  respond  as  soon  as  possible  to  provide  advanced  clinical  assessment  and 
interventions  where  required,  which ASP  crews,  who  are  not  registered  healthcare 
professionals, are not able or authorised to provide. 

Consequently, there will be a small number of occasions where a double-ASP crew 
arrives at a C1 incident before a paramedic. This does not however mean that ASPs 
are deployed to provide prolonged autonomous management of critically ill or injured 
patients  requiring  advanced  clinical  interventions.  Rather,  their  role  in  these 
circumstances  is  to  initiate  immediate  life-saving  care  pending  the  arrival  of  a 
registered  paramedic.  Evaluation  of  the  deployment  model  has  demonstrated  that, 
where double-ASP crews require paramedic support, a paramedic resource arrives, 
on  average,  within  3.26  minutes,  providing  timely access  to advanced  clinical  care, 
oversight, and escalation. 

2 

 
 We would also suggest that it would not be accurate to characterise ASPs as often 
being first on scene for an out of hospital cardiac arrest. Historical NEAS data covering 
the  period  of  December  2024  to  May  2025  identified  that,  of  the  19,608  C1  calls 
responded to by NEAS during this period, 251 involved a double-ASP response, which 
is approximately 1.3% of cases. Therefore, whilst the deployment model deliberately 
allows  double-ASP  crews  to  respond  first  in  limited  C1  cases,  namely  where  this 
facilitates  an  earlier  opportunity  to  deliver  immediate  life-saving  interventions,  the 
available  data  indicates  that  this  represents  a  very  small  proportion  of  overall 
ambulance  responses  to  C1  calls  and  that double-ASP  crews are  not  often  first on 
scene for out-of-hospital cardiac arrests. 

Part (iii) – ASPs and Airway Management 

ASPs are trained and authorised to independently undertake a structured approach to 
basic  airway  management  in  accordance  with  JRCALC  guidance.  JRCALC  is 
nationally issued clinical guidance, governed by the Joint Royal Colleges Ambulance 
Liaison Committee, that is utilised by ambulance services nationwide. This includes 
management techniques such as airway positioning and manoeuvres, suction, bag-
valve-mask ventilation, insertion of oropharyngeal and nasopharyngeal airways, and 
ongoing  assessment  of  airway  patency  and  ventilation.  These  interventions  enable 
ASPs to establish and maintain a patent airway and provide effective ventilation while 
awaiting,  or  working  alongside,  a  registered  paramedic  or  other  healthcare 
professional. 

An i-gel is a type of supraglottic airway device (‘SGA’) and, unlike an oropharyngeal 
airway  (‘OPA’)  or  nasopharyngeal  airway  (‘NPA’)  which  are  airway  adjuncts 
authorised for insertion by ASPs and used to help maintain upper airway patency, an 
SGA is positioned above the laryngeal opening and is intended to provide a conduit 
through which the lungs can be ventilated. In practical terms, this means an SGA is 
situated deeper in the patient’s throat than an OPA or NPA would be. Please see the 
below images for comparison: 

OPA: 

3 

 
 SGA: 

Therefore,  the  use  of  an  SGA  involves  additional  considerations  beyond  those 
associated with the insertion of an OPA or NPA, including ensuring appropriate patient 
and  device  selection,  assessment  of  placement,  confirmation  that  ventilation  is 
effective, and continued monitoring of the position and function of the device. As such, 
the  insertion  of  an  SGA,  including  i-gels,  is  considered  an  advanced  airway 
management intervention, of which ASPs are not presently authorised to undertake 
independently by NEAS. 

The  classification  of  i-gel  use  as  an  advanced  airway  management  intervention  is 
supported by the national and UK evidence base. The AIRWAYS-2 trial, which was a 
large  UK  multicentre  randomised  controlled  trial  involving  ambulance  services, 
specifically evaluated the i-gel supraglottic airway against tracheal intubation as the 
initial  ‘advanced  airway  management’  strategy  used  by  paramedics  in  adult  out-of-
hospital  cardiac  arrests.  Current  Resuscitation  Council  UK  guidance  similarly 
describes  a  stepwise  approach  to  airway  management  during  resuscitation, 
progressing  from  basic  airway  techniques  according  to  the  patient's  needs  and  the 
skills  of  the  rescuer,  to  more  advanced  techniques,  with  SGAs  forming  part  of  the 
escalation in airway management. 

Therefore,  within  this  context,  NEAS  considers  i-gel  insertion  to  constitute  an 
advanced airway management intervention and therefore requires its use by ASPs to 
take place under the supervision or direction of a registered healthcare professional. 
Although ASPs do receive training in the practical insertion of SGAs, safe and effective 
use  extends  beyond  the  physical  act  of  device  placement  and  requires  effective 
assessment of the patient and their airway, selection of an appropriate airway strategy, 
recognition  and  management  of  any 
confirmation  of  effective  ventilation, 
complications, ongoing reassessment, and the ability to modify or escalate the airway 
strategy where ventilation is ineffective. 

It is important to recognise that some risks associated with airway management are 
not exclusive to SGAs. Ineffective ventilation, airway obstruction, gastric insufflation, 

4 

 
 regurgitation,  and  aspiration  may  also  occur  during  basic  airway  management, 
including  bag-valve-mask  ventilation. ASPs  therefore  are  trained  to  recognise  and 
manage these risks within their defined scope of practice. However, the distinction in 
relation  to  an  i-gel,  and  SGAs  more  generally,  is  that  the  insertion  of  such  devices 
introduces additional device-specific considerations and risks not otherwise present, 
including  risks  surrounding  incorrect  positioning,  displacement,  inadequate  seal,  air 
leak, and failure to achieve or maintain effective ventilation. Airway trauma may also 
occur. Apparent  successful  insertion  of  an  i-gel  does  not,  in  itself,  confirm  that  the 
ventilation is effective, and the patient's response, chest movements, and ventilation 
characteristics  must  be  assessed  and  continually  reassessed  with  waveform 
capnography (which is a system to monitor exhaled carbon dioxide). The wider clinical 
context and anticipated progression of the care following the insertion of the i-gel must 
also be considered, including the cause of the cardiac arrest, the availability and skills 
of  attending  personnel,  the  need  to  minimise  interruptions  to  other  time-critical 
interventions, and whether an alternative airway strategy is more appropriate. Failure 
to achieve or maintain adequate ventilation should prompt immediate reassessment 
and consideration of an alternative airway management strategy. 

Therefore,  in  short,  there  are  additional  considerations  and  risks  to  a  patient  when 
inserting an SGA, which are not present when inserting an OPA or NPA. 

The distinction in authorisation is therefore not based solely on whether an ASP has 
been  taught  and  demonstrated  competence  in  the  technique  of  inserting  an  i-gel. 
Rather, it reflects the broader clinical decision-making, risk assessment, and ongoing 
management  that  is  unavoidably  required  with  progression  from  basic  airway 
management to more advanced techniques, such as the insertion of an SGA. For this 
reason, NEAS’ position remains that ASPs may independently undertake the specified 
basic airway interventions within their authorised scope of practice, whilst the insertion 
of  an  i-gel  by  an  ASP  should  take  place  under  the  supervision  or  direction  of  a 
registered  healthcare  professional,  as,  for  this  take  place  without  such  supervision, 
would present an unacceptable level of additional risk to the patient, and unreasonable 
clinical expectation on ASPs who are not registered healthcare professionals. 

Part (iv) - Conclusion 

In conclusion, it remains NEAS’ position that ASPs should only insert an i-gel under 
the supervision or direction of a registered healthcare professional, which is based on 
patient safety, defined scopes of practice, and clinical governance. ASPs are trained 
and authorised to independently undertake basic airway management techniques and 
to  recognise  and  respond  to  complications  associated  with  those  interventions. 
However,  the  use  of  an  i-gel  represents  a  progression  to  advanced  airway 
management  and  introduces  additional  clinical  and  device-specific  considerations, 
including appropriate airway strategy, confirmation and ongoing monitoring of effective 
ventilation, recognition of device displacement or failure, and the ability to modify or 
escalate the airway management plan where required.  

5 

 
 While ASPs may be trained and competent in the technical skill of i-gel insertion, the 
Trust  considers  that  the  broader  clinical  decision-making,  risk  assessment,  and 
ongoing management associated with its use should remain under the oversight of a 
registered  healthcare  professional.  This  approach  enables  ASPs  to  contribute 
effectively  to  the  management  of  critically  unwell  patients,  including  initiating 
immediate life-saving airway and ventilation interventions when first on scene, while 
ensuring  that  progression  to  advanced  airway  management  is  supported  by  the 
appropriate level of clinical oversight and accountability. 

Finally,  it  should  be  borne  in  mind  that ASPs  are  rarely  the  first  responders  to  C1 
incidents, occurring in only an estimated 1.3% of cases, and on average will be backed 
up by a paramedic-led resource within 3.26 minutes, who are authorised and able to 
commence  advanced  airway  management  techniques,  whilst  also  appropriately 
monitoring and managing patient risk. 

I  trust  that  this  response  provides  you  and  Edie’s  family  with  the  re-assurance  that 
NEAS has thoroughly considered your concerns to ensure that patient safety in such 
critical incidents is preserved and enhanced insofar as possible. If it would be helpful, 
we would gladly arrange a meeting with our internal Paramedicine team so you can 
discuss this matter further.  

May I once again pass on my sincere condolences to the family of Edie. If we can be 
of any further assistance then please do not hesitate to 
 Director of 
Quality and Safety, via email at 

Yours Sincerely  

Chief Executive 

6