NHS England
NHS / Health Body
Action Taken
NHS England describes the role of the Emergency Call Prioritisation Advisory Group (ECPAG) in managing ambulance service prioritisation, referencing the NHS Pathways product and its alignment with clinical standards. They also note that NHS Pathways enhanced the toxic ingestion template in PaCCS in 2021 to improve access to TOXBASE and that all PFD reports are discussed by a working group. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Fern Elisabeth Foster who died on 8 July 2020
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 June 2024 concerning the death of Fern Elisabeth Foster on 8 July 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Fern’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Fern’s care have been listened to and reflected upon.
Your first concern relates to the process for triaging and prioritising ambulance attendance to an incident involving , and that this does not provide sufficient opportunity for emergency treatment.
Assessment and prioritisation of cases usually occurs in Urgent and Emergency Care (UEC) settings; in this instance the 999 ambulance service. The prioritisation of cases by ambulance services is managed through NHS England’s Emergency Call Prioritisation Advisory Group (ECPAG). This group has membership from the Association of Ambulance Chief Executives, National Ambulance Service Medical Directors and wider clinical stakeholders, along with the in-house UEC triage product (NHS Pathways) clinical leadership. The group reviews data, trends and clinical evidence (including NHS Pathways data) provided from the ambulance Clinical Reference Group (CRG) to determine the case-mix in the ambulance categories. The NHS Pathways product is then built against these standards, and alignment to these standards, and other clinical guidance, is assured by the National Clinical Advisory Group (NCAG) hosted by the Academy of Medical Royal Colleges (AoMRC).
Overdoses, whether intentional or accidental, can be challenging cases to assess remotely; many different substances, medicines, doses and combinations are possible. This poses challenges to classify and appraise the relative lethality of the substances involved and balance this risk against the symptoms and circumstances at the time of the call. Where an overdose has occurred, and in the absence of signs or symptoms indicating an immediate life-threat (reduced consciousness level, breathlessness or shock, for example), the lowest disposition that can be reached is a Category 3 ambulance response. A higher response will be reached where there are symptoms indicating an immediate life threat.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
29/07/2024
NHS England issued communications to ambulance services and NHS 111 providers in 2019 and 2021 in respect of managing overdose cases, and in November 2023 an updated version was issued instructing that any case reaching a Category 3 response should have further clinical assessment within a set timeframe, or else be automatically upgraded to a Category 2 response. Further details are set out below.
“High risk” vs “low risk” substances The objective of further remote clinical assessment is to determine the likely threat to the patient by gathering the clinical information about the substance(s) ingested and their quantities. Clinicians using specific modules of the NHS Pathways product are recommended to use TOXBASE® to support their assessment.
TOXBASE is the clinical toxicology database of the UK National Poisons Information Service that clinicians have access to, to help support clinical decision making when excess medications have been ingested.
Health advisors are not clinically trained. Their training ensures an understanding of the limits to their scope of practice so that they seek supervisory, or clinical, support where appropriate. This includes instances where medical information, such as medication names, are volunteered during the assessment and they are not expected to understand or identify medication names or drug classifications.
Enabling prioritisation of cases for clinical assessment, and/or automatic upgrade To support NHS England’s 2019 communication and enable services to identify these Category 3 cases to clinicians for priority assessment, NHS Pathways developed a specific disposition code ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ in April 2019. This code facilitates improved visibility of overdose or suicide attempt cases within the ambulance dispatch queue. These actions, to develop and deploy this disposition code, were ratified by the former NHS Pathways National Clinical Governance Group (NCGG) in February 2019 (this group has been superseded by NCAG). This was also approved by NHS England’s ECPAG on 3rd July 2019. It was deployed to all service users as part of Release 18 in October 2019.
In April 2021, NHS England and Improvement, in conjunction with the Association of Ambulance Chief Executives (AACE), published a new operational procedure for all ambulance services in England entitled, “Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document”. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes, to ensure that suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above. In this 2021 document, NHS England set out that, where an overdose is declared, a further clinical intervention should take place within 30 minutes and/or the case will be automatically upgraded if this does not occur within 40 minutes. In October 2023, a review of this document was completed by ECPAG and the National Ambulance Service Medical
Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remains fit for purpose. The view from the Ambulance Response Programme Implementation Group at NHS England, supported by NASMeD, was that cases involving suicidal ideation (including overdoses) are often multi-factorial and therefore too complex for Health Advisors to apply a definitive disposition without assessment by a clinician. Instead, they require an urgent remote clinical risk assessment in the absence of priority airway, breathing or circulation symptoms during triage. This means that for those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response. If, however, on review the clinical view is that, given the individual factors of the case this should be upgraded to a Category 1 or 2 emergency ambulance response, this is done without delay.
NHS Pathways consulted with their Clinical Stakeholder Group (CSG) in November 2021 and March 2022 to discuss the challenges of dealing with overdose calls. The consensus was that Health Advisors are not best suited to dealing with medication complexities, such as medication names, staggered overdoses, involvement of recreational drugs, interaction of other medications and other patient specific factors. The consensus was that clinical reasoning was required with the use of TOXBASE, and that the current process was most suitable.
In addition to the core telephony product, NHS Pathways also provides a telephone consultation tool called Pathways Clinical Consultation Support System (PaCCS). This is for use by experienced clinicians and comprises a suite of clinical templates based on existing NHS Pathways clinical content. These templates are presented in a list format which provides the user with a less prescriptive tool, lending itself more to a consultation-led assessment rather than triage. Within each clinical template, there is additional supporting information and links to approved websites that can be viewed if required by the user. In November 2021, as a result of learning from another case, NHS Pathways enhanced the toxic ingestion template in PaCCS to ensure clinical users were given clear and concise information to access TOXBASE, and they were also provided with the web link to do so.
Should national guidance or standards be amended such that toxic substances, where identified, impact on ambulance categorisation or disposition, NHS England would align the NHS Pathways product accordingly.
Your second concern relates to the fact that it is not regional or national protocol for ambulance services to carry antidote medication for on-scene administration.
The carrying of specific medications by ambulance services is an operational issue and is up to individual ambulance trusts; NHS England does not mandate such issues.
NHS England is aware of a small number of ambulance specialist units who carry . This antidote is carried by specialist clinical teams for administration
in cases of , which can be measured through an exhaled breath monitor. Clinical feedback suggests it is likely that would not be used except for severe cases or where there is a long journey time to definitive care.
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 Fern, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 June 2024 concerning the death of Fern Elisabeth Foster on 8 July 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Fern’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Fern’s care have been listened to and reflected upon.
Your first concern relates to the process for triaging and prioritising ambulance attendance to an incident involving , and that this does not provide sufficient opportunity for emergency treatment.
Assessment and prioritisation of cases usually occurs in Urgent and Emergency Care (UEC) settings; in this instance the 999 ambulance service. The prioritisation of cases by ambulance services is managed through NHS England’s Emergency Call Prioritisation Advisory Group (ECPAG). This group has membership from the Association of Ambulance Chief Executives, National Ambulance Service Medical Directors and wider clinical stakeholders, along with the in-house UEC triage product (NHS Pathways) clinical leadership. The group reviews data, trends and clinical evidence (including NHS Pathways data) provided from the ambulance Clinical Reference Group (CRG) to determine the case-mix in the ambulance categories. The NHS Pathways product is then built against these standards, and alignment to these standards, and other clinical guidance, is assured by the National Clinical Advisory Group (NCAG) hosted by the Academy of Medical Royal Colleges (AoMRC).
Overdoses, whether intentional or accidental, can be challenging cases to assess remotely; many different substances, medicines, doses and combinations are possible. This poses challenges to classify and appraise the relative lethality of the substances involved and balance this risk against the symptoms and circumstances at the time of the call. Where an overdose has occurred, and in the absence of signs or symptoms indicating an immediate life-threat (reduced consciousness level, breathlessness or shock, for example), the lowest disposition that can be reached is a Category 3 ambulance response. A higher response will be reached where there are symptoms indicating an immediate life threat.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
29/07/2024
NHS England issued communications to ambulance services and NHS 111 providers in 2019 and 2021 in respect of managing overdose cases, and in November 2023 an updated version was issued instructing that any case reaching a Category 3 response should have further clinical assessment within a set timeframe, or else be automatically upgraded to a Category 2 response. Further details are set out below.
“High risk” vs “low risk” substances The objective of further remote clinical assessment is to determine the likely threat to the patient by gathering the clinical information about the substance(s) ingested and their quantities. Clinicians using specific modules of the NHS Pathways product are recommended to use TOXBASE® to support their assessment.
TOXBASE is the clinical toxicology database of the UK National Poisons Information Service that clinicians have access to, to help support clinical decision making when excess medications have been ingested.
Health advisors are not clinically trained. Their training ensures an understanding of the limits to their scope of practice so that they seek supervisory, or clinical, support where appropriate. This includes instances where medical information, such as medication names, are volunteered during the assessment and they are not expected to understand or identify medication names or drug classifications.
Enabling prioritisation of cases for clinical assessment, and/or automatic upgrade To support NHS England’s 2019 communication and enable services to identify these Category 3 cases to clinicians for priority assessment, NHS Pathways developed a specific disposition code ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ in April 2019. This code facilitates improved visibility of overdose or suicide attempt cases within the ambulance dispatch queue. These actions, to develop and deploy this disposition code, were ratified by the former NHS Pathways National Clinical Governance Group (NCGG) in February 2019 (this group has been superseded by NCAG). This was also approved by NHS England’s ECPAG on 3rd July 2019. It was deployed to all service users as part of Release 18 in October 2019.
In April 2021, NHS England and Improvement, in conjunction with the Association of Ambulance Chief Executives (AACE), published a new operational procedure for all ambulance services in England entitled, “Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document”. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes, to ensure that suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above. In this 2021 document, NHS England set out that, where an overdose is declared, a further clinical intervention should take place within 30 minutes and/or the case will be automatically upgraded if this does not occur within 40 minutes. In October 2023, a review of this document was completed by ECPAG and the National Ambulance Service Medical
Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remains fit for purpose. The view from the Ambulance Response Programme Implementation Group at NHS England, supported by NASMeD, was that cases involving suicidal ideation (including overdoses) are often multi-factorial and therefore too complex for Health Advisors to apply a definitive disposition without assessment by a clinician. Instead, they require an urgent remote clinical risk assessment in the absence of priority airway, breathing or circulation symptoms during triage. This means that for those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response. If, however, on review the clinical view is that, given the individual factors of the case this should be upgraded to a Category 1 or 2 emergency ambulance response, this is done without delay.
NHS Pathways consulted with their Clinical Stakeholder Group (CSG) in November 2021 and March 2022 to discuss the challenges of dealing with overdose calls. The consensus was that Health Advisors are not best suited to dealing with medication complexities, such as medication names, staggered overdoses, involvement of recreational drugs, interaction of other medications and other patient specific factors. The consensus was that clinical reasoning was required with the use of TOXBASE, and that the current process was most suitable.
In addition to the core telephony product, NHS Pathways also provides a telephone consultation tool called Pathways Clinical Consultation Support System (PaCCS). This is for use by experienced clinicians and comprises a suite of clinical templates based on existing NHS Pathways clinical content. These templates are presented in a list format which provides the user with a less prescriptive tool, lending itself more to a consultation-led assessment rather than triage. Within each clinical template, there is additional supporting information and links to approved websites that can be viewed if required by the user. In November 2021, as a result of learning from another case, NHS Pathways enhanced the toxic ingestion template in PaCCS to ensure clinical users were given clear and concise information to access TOXBASE, and they were also provided with the web link to do so.
Should national guidance or standards be amended such that toxic substances, where identified, impact on ambulance categorisation or disposition, NHS England would align the NHS Pathways product accordingly.
Your second concern relates to the fact that it is not regional or national protocol for ambulance services to carry antidote medication for on-scene administration.
The carrying of specific medications by ambulance services is an operational issue and is up to individual ambulance trusts; NHS England does not mandate such issues.
NHS England is aware of a small number of ambulance specialist units who carry . This antidote is carried by specialist clinical teams for administration
in cases of , which can be measured through an exhaled breath monitor. Clinical feedback suggests it is likely that would not be used except for severe cases or where there is a long journey time to definitive care.
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 Fern, 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.