NHS England
NHS / Health Body
Noted
NHS England expresses condolences and states that concerns have been listened to and reflected upon. They highlight the remit of other organisations (NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust) regarding some of the concerns, and reference workstreams to increase ambulance capacity and improvements to Tameside's ED. They also note the discussion of PFD reports by their Regulation 28 Working Group to share learnings. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Bernard Compton who died on 19 October 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 June 2024 concerning the death of Bernard Compton on 19 October 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Bernard’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Bernard’s care have been listened to and reflected upon.
My response to you focuses on those concerns raised in your Report that come under the remit of NHS England’s national policy or programme work. It would be more appropriate for the North West Ambulance Service (NWAS) NHS Trust and Tameside and Glossop Integrated Care NHS Foundation Trust to respond to some of the concerns raised, and you may wish to revert to those Trusts for further information.
One of the concerns raised in your Report relates to the NWAS call algorithm and the fact that this did not pick up that Bernard was exhibiting symptoms of an ongoing myocardial infarction (MI), which resulted in the initial allocation of a Category 3 response when Bernard’s condition was time critical.
The NHS Pathways product team provides the NHS Pathways Clinical Decision Support System (CDSS) urgent and emergency triage product. This product is used in NHS 111 and over half of 999 ambulance services in England, including NWAS, supporting the remote assessment of over 23 million calls a year. It is embedded within host systems in those providers and interacts with other technology products to support the assessment, sorting and onward management of calls received by those services.
Calls to services using the NHS Pathways triage product are managed by specially trained non-clinical Health Advisers. Their training is specific to the Pathways product, and this enables them to use the information provided by callers to pass cases to suitable services, based on the patient’s health needs at the time of the call. NHS Pathways trained call handlers are supported by clinicians who may provide advice and guidance, or to whom calls may be transferred, when required.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
25 July 2024
The NHS Pathways triage product is built to progress through a clinical hierarchy of urgency. This means that life-threatening problems are assessed first, and less urgent problems are assessed sequentially thereafter. The endpoint of an assessment is reached when a clinically significant factor cannot be ruled out and so a “disposition” is reached. Dispositions range from ‘Emergency Ambulance’ to ‘Self-Care’.
NHS Pathways is not a diagnostic system, and it assesses symptoms presented at the time of the call and signposts to the next level of care by asking a series of questions which progress through a clinical hierarchy of urgency. Accordingly, in recognition of the seriousness of the conditions, questions seeking to identify symptoms of a MI and heart attack are part of the questions asked at an early stage.
Within the Chest Pain Pathway, a Category 2 ambulance response is reached for patients with active chest pain, or chest pain within 24 hours for those with a past cardiac history, any risk factors such as an abdominal aortic aneurysm or Marfan’s Syndrome, or those showing signs of sepsis. NHS Pathways recognises that cardiac symptoms can have multiple presentations, and therefore the system also accounts for pain in the upper back, between the shoulder blades, and in the arms, shoulders, neck or jaw.
As part of their training, Health Advisers learn about probing for more information if answers are unclear, or if callers do not know how to respond to a question, and NHS Pathways supports this through the use of prompts alongside questions.
Clinical input can be sought at any point during the call by the Health Advisers. Health Advisers can also ‘early exit’ a call if they believe it to be complex and pass it directly to a Clinical Adviser. A complex call is defined as ‘any call which isn’t straightforward and where the Health Adviser determines that they are working at or beyond the limits of their knowledge’.
In this case, during the first call to NWAS, the Health Adviser identified that Bernard was experiencing pain under his arm, shaking, sweating and breathlessness as the main symptoms, and selected the Arm Pain or Swelling Pathway. Had further probing around the location or nature of the pain occurred, it is possible that the Health Adviser may have selected chest pain as a main symptom, allowing for further interrogation into the symptoms and the possibility of a Category 2 ambulance response being reached. Furthermore, if Bernard was unable to identify his main symptom, this call could have been escalated as a complex call, enabling a Clinical Adviser to assess the symptoms instead. However, Benard did not report chest pain when asked during the call, as well as stating that he had not had a previous heart attack, which therefore resulted in a Category 3 ambulance response within the Arm Pain or Swelling Pathway. During the two subsequent calls from the Greater Manchester Police, a Category 2 ambulance response was reached in response to the declared chest pain.
My regional colleagues in the North West have also engaged with NWAS on your concerns and are advised that NWAS have identified that the call was safely and appropriately triaged as Category 3 with the symptoms provided by Bernard on the initial call. It was identified by NWAS at the time that the call was potentially suitable to be supported by clinician callback and details were sent to the Greater Manchester Clinical Assessment Service (GMCAS) for clinical assessment, as per agreed
governance processes and to assess if other local services could support Bernard’s needs.
Following GMCAS contact with Bernard, they contacted NWAS to arrange transport for Bernard to the local Emergency Department at Tameside General Hospital.
There was significant demand on both NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust in the Autumn of last year, with the Emergency Department (ED) at Tameside under significant pressure and all areas of the ED full. Health systems remain in recovery following the COVID-19 pandemic and pressures arising from it and the societal response. NHS England’s recovery plans include a focus on Urgent and Emergency Care, with one of the plan’s nine workstreams including increasing ambulance capacity. Since October 2023, Tameside’s ED has increased its capacity as part of a planned rebuild of the unit. My regional colleagues have approached the Greater Manchester Integrated Care Board (ICB) for further information regarding your concerns, as the local commissioner of the Trust. As referenced above, you may also wish to approach the relevant Trusts or the ICB for further information.
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 Bernard, 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 5 June 2024 concerning the death of Bernard Compton on 19 October 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Bernard’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Bernard’s care have been listened to and reflected upon.
My response to you focuses on those concerns raised in your Report that come under the remit of NHS England’s national policy or programme work. It would be more appropriate for the North West Ambulance Service (NWAS) NHS Trust and Tameside and Glossop Integrated Care NHS Foundation Trust to respond to some of the concerns raised, and you may wish to revert to those Trusts for further information.
One of the concerns raised in your Report relates to the NWAS call algorithm and the fact that this did not pick up that Bernard was exhibiting symptoms of an ongoing myocardial infarction (MI), which resulted in the initial allocation of a Category 3 response when Bernard’s condition was time critical.
The NHS Pathways product team provides the NHS Pathways Clinical Decision Support System (CDSS) urgent and emergency triage product. This product is used in NHS 111 and over half of 999 ambulance services in England, including NWAS, supporting the remote assessment of over 23 million calls a year. It is embedded within host systems in those providers and interacts with other technology products to support the assessment, sorting and onward management of calls received by those services.
Calls to services using the NHS Pathways triage product are managed by specially trained non-clinical Health Advisers. Their training is specific to the Pathways product, and this enables them to use the information provided by callers to pass cases to suitable services, based on the patient’s health needs at the time of the call. NHS Pathways trained call handlers are supported by clinicians who may provide advice and guidance, or to whom calls may be transferred, when required.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
25 July 2024
The NHS Pathways triage product is built to progress through a clinical hierarchy of urgency. This means that life-threatening problems are assessed first, and less urgent problems are assessed sequentially thereafter. The endpoint of an assessment is reached when a clinically significant factor cannot be ruled out and so a “disposition” is reached. Dispositions range from ‘Emergency Ambulance’ to ‘Self-Care’.
NHS Pathways is not a diagnostic system, and it assesses symptoms presented at the time of the call and signposts to the next level of care by asking a series of questions which progress through a clinical hierarchy of urgency. Accordingly, in recognition of the seriousness of the conditions, questions seeking to identify symptoms of a MI and heart attack are part of the questions asked at an early stage.
Within the Chest Pain Pathway, a Category 2 ambulance response is reached for patients with active chest pain, or chest pain within 24 hours for those with a past cardiac history, any risk factors such as an abdominal aortic aneurysm or Marfan’s Syndrome, or those showing signs of sepsis. NHS Pathways recognises that cardiac symptoms can have multiple presentations, and therefore the system also accounts for pain in the upper back, between the shoulder blades, and in the arms, shoulders, neck or jaw.
As part of their training, Health Advisers learn about probing for more information if answers are unclear, or if callers do not know how to respond to a question, and NHS Pathways supports this through the use of prompts alongside questions.
Clinical input can be sought at any point during the call by the Health Advisers. Health Advisers can also ‘early exit’ a call if they believe it to be complex and pass it directly to a Clinical Adviser. A complex call is defined as ‘any call which isn’t straightforward and where the Health Adviser determines that they are working at or beyond the limits of their knowledge’.
In this case, during the first call to NWAS, the Health Adviser identified that Bernard was experiencing pain under his arm, shaking, sweating and breathlessness as the main symptoms, and selected the Arm Pain or Swelling Pathway. Had further probing around the location or nature of the pain occurred, it is possible that the Health Adviser may have selected chest pain as a main symptom, allowing for further interrogation into the symptoms and the possibility of a Category 2 ambulance response being reached. Furthermore, if Bernard was unable to identify his main symptom, this call could have been escalated as a complex call, enabling a Clinical Adviser to assess the symptoms instead. However, Benard did not report chest pain when asked during the call, as well as stating that he had not had a previous heart attack, which therefore resulted in a Category 3 ambulance response within the Arm Pain or Swelling Pathway. During the two subsequent calls from the Greater Manchester Police, a Category 2 ambulance response was reached in response to the declared chest pain.
My regional colleagues in the North West have also engaged with NWAS on your concerns and are advised that NWAS have identified that the call was safely and appropriately triaged as Category 3 with the symptoms provided by Bernard on the initial call. It was identified by NWAS at the time that the call was potentially suitable to be supported by clinician callback and details were sent to the Greater Manchester Clinical Assessment Service (GMCAS) for clinical assessment, as per agreed
governance processes and to assess if other local services could support Bernard’s needs.
Following GMCAS contact with Bernard, they contacted NWAS to arrange transport for Bernard to the local Emergency Department at Tameside General Hospital.
There was significant demand on both NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust in the Autumn of last year, with the Emergency Department (ED) at Tameside under significant pressure and all areas of the ED full. Health systems remain in recovery following the COVID-19 pandemic and pressures arising from it and the societal response. NHS England’s recovery plans include a focus on Urgent and Emergency Care, with one of the plan’s nine workstreams including increasing ambulance capacity. Since October 2023, Tameside’s ED has increased its capacity as part of a planned rebuild of the unit. My regional colleagues have approached the Greater Manchester Integrated Care Board (ICB) for further information regarding your concerns, as the local commissioner of the Trust. As referenced above, you may also wish to approach the relevant Trusts or the ICB for further information.
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 Bernard, 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.