Joanna Kowalczyk

Dear Miss Benyounes,

Inquest into the death of Joanna Kowalczyk Regulation 28 – Report to prevent future deaths 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 21 January 2025 as issued by you following the inquest into the tragic death of Joanna Kowalczyk. 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 Joanna. I am aware that the report was also issued to the General Chiropractic Council. We will not address this specific concern and simply respond to that specifically related to NEAS. I will address the NEAS point you have raised in your matters of concern below: -

1. The evidence from the attending paramedic was that she was not aware that symptoms of a stroke can stop after a short time as clearly set out on NHS website and guidance, and that this was not part of her training. This was directly contrary to the Head of Operations’ evidence that this was part of both paramedic training and annual continuing professional development. This was a concerning feature given the accepted evidence of the time critical period to treat patients with symptoms potentially indicative of stroke. In respect to the NHS website this contains information for the public in relation to stroke which I believe is what the family pointed out. The information is however directed towards the public in so far that the symptoms section contains the statement ‘symptoms of a stroke can sometimes stop after a short time, so you may think you're OK. Even if this happens, get medical help straight away’. The following link will direct you onto the information which I believe is referenced https://www.nhs.uk/conditions/stroke/. This is not intended to provide guidance to health professionals and directs the public to seek medical help which is what happened in this case.

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

Tel : 0191 430 2000

Ref:

Strictly Private and Confidential Miss Leila Benyounes His Majesty's Assistant Coroner for Gateshead and South Tyneside Coroner Office, Town Hall and Civic Offices, Westoe Road, South Shields, Tyne and Wear, NE33 2RL

Date: 16th April 2025

I am aware that evidence from one of the attending Paramedics led you to believe that they were not trained to recognise that symptoms of a stroke could cease after a period of time. This was despite the Head of Operations confirming in evidence that firstly he thought the Paramedic had not understood the question. The evidence provided by the Head of Operations described how Paramedics were trained and that secondly, he would ensure that following the inquest he would feed this back to the Paramedic and send a wider update to the Paramedic cohort at the Trust reminding them of the potential for stroke symptoms to dissipate over time. Further to the conclusion of the inquest the Paramedic took it upon themselves to write a detailed Continual Professional Development (CPD) piece to demonstrate their understanding of Stroke and Transient Ischemic Attack (TIA). In respect to the education and training of Paramedics I have set out the education journey and the ongoing CPD undertaken as a registered healthcare professional. Academic Education via University

During Paramedic training (this is the 3-year BSc or the older 2-year paramedic degrees), Stroke/ TIA and neurological conditions are all covered and how to recognise signs and symptoms. During the sessions covering Stroke/TIA, students are informed and taught that symptoms may have resolved on arrival but anyone who has displayed symptoms of a Stroke/TIA which have resolved will not be left on scene but referred to another healthcare professional. This would usually mean conveyance to the local hospital and/or the stroke unit should be contacted. Students are taught that symptoms of a stroke that have ‘resolved’ could be a red flag/ predisposing factor to a further stroke.

1. An example of a university course is Teesside university and the internal NEAS students (BSc level), year one includes a neurological module which talks about each condition and then how to assess symptoms which includes observations, pupil response, FAST (face, arms, speech, time), AcVPU (alert, new confusion, voice, pain, unresponsive) consciousness and GCS (glasgow coma scale), and goes into further detail such as the cranial nerve assessment. All of these points are discussed including how to identify any abnormalities.

2. Year two provides further in depth education/training in respect to the neurological system, symptoms and assessment. An example of learning is a journal article ‘a survey of UK Paramedics’ views about stroke training, current practice and the identification of stroke mimics’ by Dr Graham McClelland et al.

3. Year three education/training revisits the elements of the previous years, including signs and symptoms. This does not include additional new information and acts as a continuation of previous learning by students to ensure it is embedded learning.

Initial Onboarding Course

Stroke and Transient Ischaemic Attack (TIA) is covered in education and training for Ambulance Care Assistants (ACA), Ambulance Support Practitioners (ASP) and Paramedics. Training for ACA/ASP include how to recognise signs and symptoms Stroke and Transient Ischaemic Attack (TIA). Newly Qualified Paramedics (NQP) and Qualified Paramedics courses do not revisit their previous education and training, however training covers stroke pathways and bypass care bundles. The term ‘care bundles’ relates to a collection of interventions that may be applied to the management of a particular condition i.e. stroke pathway. These care bundles are also covered in the Electronic Patient Care Record (EPCR) training alongside how to complete accurate documentation.

Newly Qualified Paramedic (NQP) Portfolio (band 5)

After graduation, Newly Qualified Paramedics (NQPs) have up to two years to complete their Newly Qualified Paramedics portfolio. This is nationally recognised process and is completed by all Newly Qualified Paramedics. Part of the portfolio is to document progression, including meetings with Mentors and identifying areas of development. During these sessions discussions include patient assessments and clinical decision-making. The process does not include anything specific for ‘neurological’, however throughout process of completing the portfolio evidence is collated to cover physical examinations, risk assessments, appropriate decision making, the use of clinical judgment to select most likely diagnosis in relation to evidence gathered, and many other areas where evidence needs to be supplied of when they have carried out that point.

During this stage of their career Newly Qualified Paramedics cannot discharge on scene, with a requirement that they ensure input of a senior clinician prior to discharging a patient at scene. As part of their continued learning and reflective practice Newly Qualified Paramedics maintain ‘clinical learning diaries’ logging specific cases they have attended, including the likes of suspected Stroke and Transient Ischaemic Attack (TIA).

Statutory and Mandatory Training

On an annual basis ambulance staff undergo statutory and mandatory training. The annual training is developed with various specialist departments agreeing what should be included and co-designing the packages prior to commencing the training programme. This approach includes any identified learning throughout the previous year and/or any changes in practice coming through external recommendations and/or requirements. Stroke training was included in the annual training in 2018/2019 and covered stroke statistics, definitions, risk factors, signs and symptoms, stroke mimics, assessment, treatment, current NEAS performance and potential areas for improvement.

The 2022/2023 statutory and mandatory training included Stroke and was delivered via a video/ e-learning presentation developed by Dr Graham McClelland, this included a focus on his Stroke research undertaken at that time. The training included a refresher on pre-hospital stroke care, recommendations, Paramedic Acute Stroke Treatment Assessment (PASTA) trial, thrombectomy, time = brain, FAST (face, arms, speech, time), pre-alerts, dispatch criteria, statistics, Electrocardiogram (ECG), Intravenous (IV) cannulation and not to delay on scene time.

Joint Royal Colleges Ambulance Liaison Committee (JRCALC)

It may be helpful to explain the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance. The JRCALC guidelines have evolved from many locally derived protocols to systematically developed national clinical practice guidelines based on current best evidence. The ongoing continuous updates are supported via the JRCALC Guideline Development Group (JRCALC-GDG), have over the years been responsible for developing and reviewing the national clinical practice guidelines for NHS Paramedics. JRCALC guidelines are also an important part of clinical risk management and ensure uniformity in the delivery of high-quality patient care. As such, they form the basis for UK Paramedic training and education. JRCALC combines expert advice with practical guidance to help Paramedics in their challenging roles and supports them in providing patient care.

The guidelines cover an extensive range of topics, from resuscitation, medical emergencies, trauma, obstetrics and medicines to major incidents and staff wellbeing. Stroke and Transient Ischaemic Attack (TIA) have a full section under JRCALC too which discusses symptoms, treatment, time critical factors. It states, ‘patients with TIA may be at high risk of stroke and require urgent specialist assessment, and local pathways should be followed’. JRCALC is broken down into the following headings: introduction, pathophysiology, incidents, severity and outcome, assessment and management, audit information and key points.

In addition to education and training all NEAS Paramedics are given access to the JRCALC guidelines through individual licenses for the JRCALC Plus app. JRCALC Plus allows individual ambulance services to combine the national guidelines with their regional information, this is achieved via individual login details linking with the specific Ambulance Trust. The app contains the following which is utilised by NEAS:

▪ Complete JRCALC Guidelines ▪ Regional and local guidance specific to NEAS ▪ Clinical Notices/Bulletins ▪ Medications information including patient group directives ▪ All updates and alerts are published in real time as new guidance is issued ▪ The app works offline and is therefore accessible to our teams

Emergency Ambulance crews can access the JRCALC Plus app via iPads which are now being transitioned to personal issue, with the rollout of personal issue devices commencing in August 2024, prior to this date the iPad (or previous electronic device) was part of the standard vehicle equipment. In addition, the clinicians have the option for the App to be downloaded on other devices such as personal smart phones if they so choose so. This allows clinicians to access the guidelines whilst at the patient side and/or when travelling to the case.

Stroke and Transient Ischaemic Attack (TIA) have a full section under JRCALC too which discusses symptoms, treatment, time critical factors. It states, ‘patients with TIA may be at high risk of stroke and require urgent specialist assessment, and local pathways should be followed’. JRCALC is broken down into the following headings: intro, pathophysiology, incidents, severity and outcome, assessment and management, audit information and Key points.

In addition to education and training provided to our staff, we have recently strengthened our Senior Clinical Leadership team. Under the leadership of our Director and Deputy Director of Paramedicine, we have appointed three Consultant Paramedics and a Head of Clinical Development and Effectiveness. The team are working closely with internal and external colleagues to develop clinical and professional leadership of our clinical workforce, developing our capabilities, standards and opportunities for development across our system. This includes a strong link into the ongoing education and training of our clinical workforce, ultimately complimenting the details I set our previously alongside ongoing CPD undertaken as registered healthcare professionals.

I trust that this response provides you and the family with the re-assurance that, as indicated by the Trust’s Head of Operations in live evidence at the inquest, staff are and continue to be educated and trained in respect to stroke and neurological conditions including the potential that symptoms of a stroke can dissipate.

If it would be helpful, we would gladly arrange a visit to our internal Education Centre so you can see our facilities and receive an overview of the education provided to our staff. May I once again pass on my sincere condolences to the family of Joanna. If we can be of any further assistance then please do not hesitate to contact , Head of Regulatory Services via email at or telephone .

Dear Ma'am_ Joanna Daria Kowalczyk Inquest: Regulation 28 Report to Prevent Future Deaths Response write to formally respond to your Prevention of Future Deaths (PFD) Report; dated 22 January 2025_ following inquest into the sad death of Ms Joanna Kowalczyk: Your concern was as follows: "2 The evidence on behalf of the treating chiropractor was that he did not consider it necessary to request GP records r hospital records, before assessment or treatment despite being informed about the Deceased's recent hospital attendance, investigation which was recommended, and her discharge against medical advice. Even in the updated consent form have been provided with, which was designed by the British Chiropractic Association, there is no prompt or question designed for the chiropractor to ask to consider obtaining medical records before assessment or treatment; and when this may be appropriate, and the only reference to medical records is a consent to communicate as deemed necessary for the treatment; and for a report to be sent to the GP after treatment, am concerned that consideration to obtaining medical records should always be given before assessment; particularly where recent medical treatment or investigations has been undertaken. As a Chiropractor registered with the General Chiropractic Council (GCC), ensure that meet the training standards and competencies set out GCC's Code of Practice, particularly, as relevant in this case, in the context of Principle C , providing a good standard of clinical care and practice: C1 Obtain and document the case history Of each patient, using suitable methods to draw out the necessary information will continue to follow the rules and guidance issued by my regulator, look forward to receiving any updated or additional guidance put in place by the GCC in response to your Regulation 28 report. If you require any further information, please let me know: