Source · Prevention of Future Deaths

Claire Briggs

Ref: 2023-0513 Date: 8 Dec 2023 Coroner: Adrian Farrow Area: Manchester South Responses identified: 13 / 13 View PDF

A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.

Date 8 Dec 2023

56-day deadline 2 Feb 2024

Responses identified 13 of 13

Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards)

Coroner's concerns

AI summary

A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.

View full coroner's concerns

The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.

Responses

13 respondents

North West Fire Control

8 Dec 2023 PDF

Action Planned

North West Fire Control is supporting the embedding of Joint Emergency Services Interoperability Principles (JESIP) and working with partners to implement electronic data transfer for improved information sharing, expected by March 2024. (AI summary)

View full response

Dear Sir

RE: Regulation 28 Report into the death of Claire Nicole Briggs

1. North West Fire Control

1.1. I write to you regarding the Regulation 28 notice issued to North West Fire Control (NWFC) on 8th December 2023 regarding the death of Claire Nicole Briggs. It is with great sadness that I read about the circumstances of her death.
1.2. NWFC was not involved in this tragic incident but is committed to learning and improvement from lessons identified. The response below explains the processes that the organisation currently has in place or planning to implement to reduce the risk of any future event that may involve NWFC. NWFC is a shared control room for Lancashire, Greater Manchester, Cumbria and Cheshire fire and rescue service. It was established in May 2014 after amalgamation of the above four fire and rescue service control rooms and is based in Warrington. It operates 24 hours a day, 365 days per year. Mr Adrian Farrow Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Lingley Mere Business Park Lingley Green Avenue Great Sankey, Warrington Cheshire,WA5 3UZ

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Date: 26th January 2024 A5

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2. Multi-Agency Interoperability

1.3. NWFC is responsible for receiving emergency calls, mobilising fire engines and other resources to incidents, liaising with the incident ground, and liaising with other emergency services and recording this information. During the 12 month period of 2022/23 year, it dealt with 135,455 emergency calls.

1.4. NWFC will deal with emergency calls in accordance with the call handling policy and procedures supplied to it by the fire and rescue service as set out in our service level agreement.
2.1. NWFC supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP), which promotes effective inter-agency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk, and Shared Situational Awareness. We ensure we follow the JESIP doctrine and use clear speech when liaising with other agencies and avoid using fire service terminology.
2.2. NWFC interacts with North West Ambulance Service (NWAS) and four police authorities in the North West region, as well as British Transport Police, sharing key information about multi-agency incidents to maintain situation awareness between each service.
2.3. After the Manchester Arena terrorist attack and subsequent recommendations from the Inquiry, the recommendations have been implemented and reviewed by NWFC and overseen through a Ministerial board. A6

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2.5. NWFC was an Interested Person during the Manchester Arena Inquiry and fully accepts the recommendations of the report and continues to embed the recommendations, including R28 and R29 (see below).

2.6. R28: North West Fire Control should take steps to ensure that it is involved in multi- agency exercises, particularly those that test mobilisation and the response to a Major Incident in line with the Joint Emergency Services Interoperability Principles (JESIP).

2.4. Part of the work linked to the Ministerial Board, led by the National Fire Chiefs Council (NFCC) and other blue light partners is to establish a process of providing additional assurance about the application of JESIP. Download the Joint Doctrine - JESIP Website.
2.7. R29: North West Fire Control should ensure that if regularly tests how it operates, by ensuring that its staff participate in regular exercises and practical tests. These should include multi-agency exercises.
2.8. NWFC has recently established an Organisation Improvement Team to compliment the audit and assurance process.
2.9. This is supported with daily testing of our inter-agency communication channels and also through ‘real life’ incidents and exercising.
2.10. NWFC adheres to the Multi Agency NFCC National Operational Guidance using agreed terminology.

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2.11. To further enhance these principles and multi-agency working with the fire and rescue services, police and NWAS, on 1st April 2023, NWFC secured funding for the appointment of a temporary ‘Inter-Agency Liaison Lead’ with specific responsibilities for the following:
2.12. Ensuring that NWFC is involved in a programme of multi-agency training and exercising to test mobilisation and response to incidents including major incidents.
2.13. To ensure that operating standards set out in NFCC endorsed National Operational Guidance and JESIP related to inter-agency working are embedded and being met.
2.14. To establish a framework for identifying shortfalls in performance relating to inter-agency working and feeding these back into internal organisational improvement processes and external multi-agency forums
2.15. To establish a multi-agency control room forum with clear Terms of Reference to, among other things, improve joint working between control rooms.

2.16. The Inter-Agency Lead has successfully established the Multi-Agency Tactical Control Communications Group which has control room representation at senior level from NWFC, Merseyside Fire Control, all North West regional Police Services, NWAS, British Transport Police and the Coastguard.

2.17. The Multi-Agency Tactical Control Communications Group has met four times and has already made positive practical change to interoperability ways of working, including sharing lessons identified from incidents, joint training and exercising.

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3. Trauma Cell

• NWFC contact NWAS emergency control room and request Trauma Cell member of staff contact fire service crews at scene immediately.
• Trauma Cell member of staff contacts fire service crews on appliance mobile phone

3.1. NWFC will support its partner fire and rescue services in dealing with incident support in accordance with the mobilising policy and procedures supplied to it by the fire service.
3.2. NWFC have supported fire and rescue services in relation to managing a request from resources at the incident ground when requesting advice from the NWAS Trauma Cell. This has been in situ since 2014.
3.3. The process ensures there is the provision for a timely assessment and prioritisation of people who require medical attention. Fire service crews at the scene of an emergency can access clinical support during protracted delays for an ambulance resource via a NWAS paramedic on the Trauma Cell. This is supported by NWFC via the following route:

3.4. In addition, NWAS updates NWFC regarding operational pressures they are facing. When NWAS REAP (Resource Escalation Action Plan) levels are escalated and therefore even higher demands than usual are placed on the ambulance service, this is shared with our partner fire and rescue services, and allows them to consider making early use of the NWAS Trauma Cell. A9

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4. NWAS Triage System

5. Right Care, Right Person

6. Multi-Agency Incident Transfer

4.1. In 2022, NWFC and its partner fire and rescue services updated their standard radio procedure to adopt the triage requirements from NWAS to enable them to make the most appropriate clinical response and assist in conveying the seriousness of any casualty’s condition, which will allow NWAS to re-categories the priority of incidents.
5.1. Right Care, Right Person (RCRP) is a framework for assisting police with decision- making about when they should be involved in responding to reported incidents involving people with mental health needs. When adopted the aim is to successfully reduce inappropriate police involvement in care and support better access to mental health specialist services.
5.2. NWFC are aware of the framework and will work with the four fire and rescue services to understand the impact on the fire services and subsequently NWFC, who will handle such calls in accordance with the fire services call handling policy and procedures.

6.1. Multi-Agency Incident Transfer (MAIT) is an electronic means of sharing information with other agencies subscribed to the MAIT hub.
6.2. NWFC have agreed to be an early adopter of MAIT within the national fire and rescue service community and aim to have this tool in place by March 2024. When the different police services and NWAS adopt this protocol, this will speed up the information sharing between emergency services using electronic data and reduce the amount of time taken for sharing information verbally via telephone/radio communications. A10

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7. Regional Standard Operating Procedure – Information Sharing

7.1. In July 2023, The Multi-Agency Tactical Control Communications Group was presented with a draft version of an information sharing document produced by NWAS to enable collaboration between NWAS and the Police.
7.2. The document was initially created in November 2021 for the Police and NWAS, and therefore based upon their own operating models, which are different to the NWFC operating model.

7.3. NWFC has provided feedback to NWAS on the document and has conducted a gap analysis of its ability to comply with the ways of working. The governance is being overseen by the NWFC’s Operations Management Committee, whose membership includes senior managers from NWFC and our four fire and rescue partners.
7.4. The principles of the document relate to gathering information and sharing situational awareness between emergency control rooms, which are also covered in the Joint Emergency Services Interoperability Principles as referred to in section 2.1

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8. NWFC wishes to pass on its condolences to family and friends of Claire Nicole Briggs and trusts this response addresses the matters raised in your regulation 28 report. NWFC will continue to adopt the JESIP principles with a view to promoting collaborative working between all emergency services.
9. Please note that as part of best practice and sharing lessons identified, I will be sharing my response with all our partner fire and rescue services.
10. If NWFC can assist the Coroner’s service any further please don’t hesitate to contact.

NHS England NHS / Health Body

8 Dec 2023 PDF

Noted

NHS England outlines existing guidance for ambulance services relating to overdoses and suicidal intent issued in April 2021, and describes ongoing work to improve ambulance performance. (AI summary)

View full response

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Claire Nicole Briggs who died on 28 November 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 December 2023 concerning the death of Claire Nicole Briggs on 28 November 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Claire’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Claire’s care have been listened to and reflected upon.

Your Report raises the concern that there is no national guidance as to how high-risk drug overdoses should be identified by ambulance services. Ambulance Emergency Operation Centres (EOCs) follow specific principles to ensure clinical oversight for patients calling and presenting with overdose and suicidal ideations. On 2 April 2019, Professor Jonathan Benger – then National Clinical Director for Urgent and Emergency Care at NHS England – wrote to ambulance trusts and NHS 111 providers to mandate that robust clinical oversight was in place in control rooms to monitor self- harm and suicidal patients safely and effectively.

In 2020, the Healthcare Safety Investigation Branch (HSIB), investigated the potentially under-recognised risk of harm from the use of propranolol. They made a safety recommendation for NHS England to evaluate current approaches to clinical oversight of overdose calls within ambulance control rooms, and to develop a national framework to describe requirements for appropriate clinical oversight of overdose calls.

NHS England issued guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. The internal guidance sets out that, where an overdose is declared, further clinical intervention should take place, or the case should be automatically upgraded if this does not occur within a specified time (30 minutes). To enable this process, NHS Pathways introduced a distinct disposition code in April 2019: Emergency Ambulance Response for Risk of Suicide (Category 3). This means these cases can be more effectively and rapidly picked out by clinical advisors at the ambulance service.

The overdose guidance was updated in November 2023 to include callers who reach a Category 5 code for overdose/accidental ingestion or a potential threat of suicide to National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

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ensure that the control room have a similar process to that for Category 3 requirements for overdose and suicidal intent patients. This followed a review by the Emergency Call Prioritisation Advisory Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remained fit for purpose.

Ambulance response dispositions within primary triage systems (e.g. NHS Pathways) are reached based on symptom assessment, and where this relates to a suicide attempt, or where there is a finding of suicidal intent, the lowest disposition that can be reached within NHS Pathways is a Category 3 emergency ambulance response. More urgent ambulance dispositions may be reached where immediately life- threatening symptoms or features are present e.g., loss of consciousness or difficulty breathing.

NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England have continued to focus on improving ambulance performance for 2023/24, supported by the Delivery Plan for Recovering Urgent and Emergency Care Services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.

Yours sincerely,

Lancashire and South Cumbria ICB Integrated Care Board

24 Jan 2024 PDF

Action Taken

Lancashire and South Cumbria ICB reports that four North West police forces have agreed and gone live with their Joint Operating Protocols (JOPs) with NWAS, with Greater Manchester Police in the final stages of agreement, and learning will be overseen by the NWAS Regional Clinical Quality Assurance Committee. (AI summary)

View full response

Dear Mr Farrow Re: Regulation 28 Prevention of Future Deaths Notice 2023-0513 – Claire Nicole Briggs Thank you for your letter dated 8th December 2023 sent following the conclusion of your inquest into the death of Claire Nicole Briggs. I understand that you will share our response with Claire’s family and I wish to pass on our sincere condolences for their loss. Through the Regulation 28 letter you have raised a concern which involves North West Ambulance Service (NWAS): ‘A Joint Operating Protocol between the North West Ambulance Service (NWAS) and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.’ As mentioned in your concern during the time of the inquest NWAS had engaged with all the North West Police Forces and were advanced in the development of a Joint Operating Protocol (JOP) for the opening, updates and closures of logs between NWAS and Police Forces. I can now confirm that four of the North West forces have now agreed and gone live with their JOPs and NWAS are making some slight amendments to the wording of the JOP with Greater Manchester Police (GMP) with the intention for this to be completed and signed off on the 1st February 2024. It will then go live in this area.

The main aims of the JOPs are to:  Ensure clear process for sharing of information between agencies, understanding of primacy and a clear escalation process for any operational issues.  Set out the process to follow for requesting open lines.  Detail the key principles for establishing a lead agency. Please contact: Email:

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 Detail the process to follow for contacting NWAS’ clinical hub. The JOP should mitigate the gap in process that you highlighted and the learning from Claire’s tragic death and progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services. I am grateful to you for raising these issues with the LSC ICB and I hope that this response has addressed the concerns raised. Should you require any further clarification or information, please do not hesitate to contact me.

Cumbria Constabulary Police / Law Enforcement

26 Jan 2024 PDF

Action Taken

Cumbria Constabulary has signed a regional Information Sharing Agreement (ISA) and has been working under a Joint Operating Procedure (JOP) since October 2023; it also provides clinical support through its "treat and hear" facility. (AI summary)

View full response

Dear Sir,

Please find below a response to the Regulation 28 Report into the death of Claire Nicole Briggs.

We have been working with NWAS and other regional police forces to agree a regional Information Sharing Agreement (ISA) as requested which has been signed by ACC Stalker on behalf of Cumbria Constabulary.

We have been working under this Joint Operating Procedure (JOP) since the 12th October 2023. The JOP outlines the roles and responsibilities of each agency, how we share information and how to escalate any incidents through the command structure.

We also have clinical support within Cumbria through our “treat and hear” facility which allows officers on the front line to provide updates direct to a member of NWAS.

If you need any more information, please do not hesitate to contact me

Regards

Deputy Chief Constable

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Lancashire Fire and Rescue Service Fire & Rescue Service

30 Jan 2024 PDF

Noted

Lancashire Fire and Rescue Service states that it was not involved in the incident, but is committed to improvement and learning. The service outlines its support for JESIP, reviews policies/procedures/training, and has an Immediate Emergency Care SOP with guidance on various areas. (AI summary)

View full response

Dear Mr Farrow REGULATION 28 REPORT INTO THE DEATH OF CLAIRE NICOLE BRIGGS Thank you for raising the concern in relation to the death of Claire Nicole Briggs on 28 November
2022. It is with great sadness that I read about the circumstances of Claire’s death and I, on behalf of Lancashire Fire and Rescue Service (LFRS), wish to pass on our condolences to the family and friends of Claire Nicole Briggs. LFRS were not involved in this tragic incident but we are committed to a culture of improvement and learning from lessons identified. LFRS actively supports and works to the Joint Emergency Services Interoperability Programme (JESIP) doctrine, promoting effective interagency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk and Shared Situational Awareness. LFRS regularly review policies, procedures and training in line with JESIP. LFRS has adopted the National Fire Chief Councils (NFCC) National Operational Guidance, which is considered good practice; this guidance has been incorporated into LFRS Standard Operating Procedures (SOP). The LFRS Immediate Emergency Care SOP clearly outlines a number of areas in relation to operational practice, dealing with casualties suffering from mental health issues, transportation of casualties, consent when responding to adults and casualty information. It is acknowledged that there are occasions when LFRS resources may arrive at an incident prior to North West Ambulance Service (NWAS). All operational personnel within LFRS are trained and assessed in immediate emergency care which is clinically governed by an external provider. Should an LFRS resource arrive prior to NWAS, LFRS personnel will assess the casualty and initiate care where necessary. Within numerous SOP’s (Communications, Gaining Entry, Immediate Emergency Care), guidance is provided for personnel to access remote clinical support. If there is a delay in NWAS response, or if the casualties condition appears to be deteriorating, personnel are directed to utilise the clinical support lines provided by NWAS Clinical Support Hub or Trauma Cell. All front line fire appliances and officers have access to these numbers via fallback telephones. Clinical advice and guidance will be provided over the phone with the potential for the NWAS response to be upgraded. Through North West Fire Control (NWFC), LFRS personnel can request; NWAS resource estimated time of arrival, NWAS categorisation of an incident, contact from NWAS Clinical Support Hub or Trauma Cell. LFRS personnel can also provide NWFC with updated casualty information which will be passed to NWAS with the potential for an upgraded response. There is a tri-service communication link between NWFC and the other blue-light emergency A21

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service control rooms. This is achieved via an Emergency Services Inter-Control Talk-Group. This line of communication is robust, resilient, practised and tested regularly. The Lancashire Resilience Forum (LRF) Emergency Radio Area Link (ERAL) is a resilient radio network which provides wide area coverage across the county of Lancashire and partial cross- border coverage into Cumbria, Yorkshire, Greater Manchester and Merseyside. ERAL has the capability to provide encrypted secure communication over voice and text and enables all Lancashire Category 1 and 2 responders (and their authorised partners) (as defined in Schedule 1 of the Civil Contingencies Act 2004) to communicate with each other during an emergency on a common radio network. The ERAL network is the preferred backup mode of communication, as detailed within the LRF Resilient Telecommunications Plan. It allows responders to maintain interoperability during events where normal communication modes are disrupted e.g., during the loss of power. Through these communication modes, there are a multitude of ways LFRS personnel can contact, (and maintain contact) with, NWAS to determine the best and most appropriate care, and advice from clinicians. NWAS update LFRS and NWFC regarding operational pressures they are facing. When NWAS REAP (Resource Escalation Action Plan) levels are escalated and demand increases, this information is shared therefore allowing LFRS personnel to consider making early use of the NWAS Trauma Cell. Although LFRS vehicles should not be used for the transportation of casualties, in exceptional circumstances, if it is deemed that transporting a casualty would potentially be a lifesaving intervention, there is a clearly defined process. This includes contacting the NWAS Trauma Cell, undertaking an on scene risk assessment and seeking authorisation from an LFRS duty officer. In response to the recommendations made, LFRS believes that appropriate guidance and processes are available and in place, and I trust this response addresses the matters raised. LFRS will continue to adopt existing JESIP principles and operational guidance, promoting collaborative working between blue-light partners, whilst striving to develop guidance and process to ensure the most effective response is delivered.

Greater Manchester ICB Integrated Care Board

31 Jan 2024 PDF

Action Taken

The North West Ambulance Service (NWAS) have engaged with all the North West Police Forces to develop a Joint Operating Protocol (JOP). Four forces have agreed and gone live with their JOPs, ensuring clear process for sharing information, primacy understanding, and a clear escalation process for any operational issues. (AI summary)

View full response

Dear Mr Farrow

Re: Regulation 28 Prevention of Future Deaths Notice 2023-0513 – Claire Nicole Briggs

Thank you for your Regulation 28 Report dated 8 December 2023 concerning the sad death of Claire Nicole Briggs on 28 November 2022. On behalf of NHS Greater Manchester Integrated Care (NHS GM), we would like to begin by offering our sincere condolences to Claire’s family for their loss.

Thank you for highlighting your concerns during the inquest. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

Following the inquest, you raised concerns in your Regulation 28 Report that there is a risk a future death will occur unless action is taken. We have worked with the 2 other ICBs in the Northwest who also use North West Ambulance Service particularly Lancashire ICB who act as a lead commissioner for the provider to review the concerns and ensure steps are taken to progress the concerns raised.

I hope the response below demonstrates to you and Claire’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case.

The evidence heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.

Whilst the court heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.

Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.

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4th Floor, Piccadilly Place, Manchester M1 3BN

As mentioned in your concern during the time of the inquest NWAS had engaged with all the North West Police Forces and were advanced in the development of a Joint Operating Protocol (JOP) for the opening, updates and closures of logs between NWAS and Police Forces. I can now confirm that four of the North West forces have now agreed and gone live with their JOPs and NWAS are making some slight amendments to the wording of the JOP with Greater Manchester Police (GMP) with the intention for this to be completed and signed off on the 1 February 2024. It will then go live in this area.

The main aims of the JOPs are to:
• Ensure clear process for sharing of information between agencies, understanding of primacy and a clear escalation process for any operational issues.
• Set out the process to follow for requesting open lines.
• Detail the key principles for establishing a lead agency.
• Detail the process to follow for contacting NWAS’ clinical hub.

The JOP should mitigate the gap in process that you highlighted and the learning from Claire’s tragic death and progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services.

Actions taken or being taken to share learning across Greater Manchester:

1. The Regulation 28 and our response to be presented/shared with the Greater Manchester System Quality Group on 21 March 2024. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services.
2. Progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice.

We hope this response demonstrates to you and Claire’s family that the North West ICBs have taken the concerns you have raised seriously and are committed to working together as a system including our service users, carers and families to improve the care provided.

Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact me should you need any further information.

Cheshire and Merseyside ICB Integrated Care Board

31 Jan 2024 PDF

Action Taken

Four of the North West police forces, including Cheshire Constabulary and Merseyside Police, have agreed and implemented Joint Operating Protocols (JOPs) with the North West Ambulance Service to improve information sharing and escalation processes. (AI summary)

View full response

Dear Mr Farrow

Re: Regulation 28 Prevention of Future Deaths Notice 2023-0513 – Claire Nicole Briggs

Thank you for your letter dated 8th December 2023 sent following the conclusion of your inquest into the death of Claire Nicole Briggs.

I understand that you will share our response with Claire’s family, and I wish to pass on our sincere condolences for their loss.

Through the Regulation 28 letter you have raised a concern which involves North West Ambu- lance Service (NWAS):

‘A Joint Operating Protocol between the North West Ambulance Service (NWAS) and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.

Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.

Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Ser- vice to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.’

As mentioned in your concern during the time of the inquest NWAS had engaged with all the North West Police Forces and were advanced in the development of a Joint Operating Protocol (JOP) for the opening, updates, and closures of logs between NWAS and Police Forces. I can now confirm that four of the North West forces including Cheshire Constabulary and Merseyside Police and have now agreed and gone live with their JOPs.

The main aims of the JOPs are to:
• Ensure clear process for sharing of information between agencies, understanding of pri- macy and a clear escalation process for any operational issues.
• Set out the process to follow for requesting open lines.
• Detail the key principles for establishing a lead agency.
• Detail the process to follow for contacting NWAS’ clinical hub.

The JOP should mitigate the gap in process that you highlighted and the learning from Claire’s tragic death and progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services.

Mr A Farrow HM Assistant Coroner HM Coroner Manchester South Email:

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NHS Cheshire and Merseyside No 1 Lakeside, 920 Centre Park Square Warrington, WA1 1QY Communications@cheshireandmerseyside.nhs.uk Cheshireandmerseyside.nhs.uk I am grateful to you for raising these issues with the NHS Cheshire and Merseyside ICB and I hope that this response has addressed the concerns raised. Should you require any further clar- ification or information, please do not hesitate to contact me.

British Transport Police Police / Law Enforcement

2 Feb 2024 PDF

Action Taken

BTP has adopted the "Ten Second Triage" (TST) tool nationally and is delivering associated training in 2024. They also use ESICTRL radio talk groups for direct communication between emergency service control rooms. (AI summary)

View full response

Dear Adrian

Thank you for your email and attachments regarding the Regulation 28 Report in the case of Claire Nicole Briggs. It was sad to read of the events that unfolded on the evening of the 28th of November 2022, that lead to the death of Claire, and our condolences are with the family at this time for their loss. Whilst the British Transport Police (BTP) were not involved in this case, and were not present at the hearing, I understand that reassurance is required regarding how BTP will ensure that the method of patient escalation is consistent with local responders and that the role of each responder is understood and communicated. Through the learning of the Manchester Arena Incident (MAI) review, BTP has improved communication between emergency services as well introducing a consistent approach to triage and identification of casualties across the UK. Whilst these reviews were as the result of the MAI, it was acknowledged that more focus was required on the triage of all incidents and not solely major incidents. Triage and Escalation As a result of the MAI enquiry, a review was carried out to look at different approaches to the triage of patients across the UK. A working group of police, ambulance and fire & rescue responders was brought together to test various triage tools available and review the outcomes. This review concluded that the methods in existence for triage were poor at identifying patients’ immediate needs that includes lifesaving intervention. As a result, the “Ten Second Triage” (TST) tool has been developed, by the National Ambulance Resilience Unit, to provide a consistent and timely method of triage; this is expected to be in place across the NHS by April 2024. BTP are also adopting this model that improves the identification of incidents/ patients requiring escalation. Actions currently underway to ensure BTP officers and staff are adequately aware of this approach include:

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OFFICIAL
• Training in TST - This is now included in the BTP annual First Aid refresher sessions for 2024 - this has already started and will be completed by mid-2024.
• Officer Briefings – These have now commenced with circulation to all officers via the BTP “Lessons Exploitation Centre” as part of a Lesson of the week Bulletin.
• Control Room Briefings – Specific communication for staff in the BTP Control Rooms have been provided to support the exchange of initial triage information with our partner responder agencies. Communication Following the major incidents of MAI and Grenfell Tower, a recommendation was made to improve communications directly between the three Emergency Service Control Rooms (3ES -Police, Fire, Ambulance). This resulted in the creation of ESICTRL (Emergency Service Inter-Control) radio talk groups that provide 24/7, uninterrupted, radio communications directly between the 3ES control rooms. There are 12 ESICTRL talk groups established nationwide that provide each region with dedicated and reliable communication channels between Police, Ambulance and the Fire Service. BTP, as a national force, monitors all 12 talk groups that include the Northwest Area Talk group, that captures NW Ambulance Service, Northwest Fire and Rescue, and GMP; this is now a live and tested communication channel. These channels have allowed BTP to support the multi-agency response to incidents that occur within/ impact on its national railway jurisdiction and ensure responder roles and responsibilities are clearly communicated and understood. The actions to introduce TST supported by the capability for BTP to communication directly with other emergency responders, via ESCTRL, provides and enhanced level of response to those victims and patients in need of time critical support.

Kind Regards,

T/Assistant Chief Constable, Public Contact and Specialist Crime

British Transport Police Address: Force Headquarters, 25 Camden Road, London NW1 9LN Email: Contact Telephone:

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NWAS Other

6 Feb 2024 PDF

Action Taken

NWAS reports that a Joint Operating Protocol (JOP) has gone live with Cheshire, Cumbria, Lancashire and Merseyside Police Forces, and that an updated version has been agreed with Greater Manchester Police and is scheduled for implementation across the whole North West following a meeting in late February 2024; also, the JOP has been extended to include British Transport Police, North West Fire Control, and Fire and Rescue Services. (AI summary)

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Dear Mr Farrow,

NWAS Response: Regulation 28 Report

Thank you for your letter dated 8 December 2023 sent following the conclusion of the inquest touching the death of Claire Nicole Briggs which commenced on 11 July 2023. I know that you will share my response with her family and I firstly want to express my sincere condolences to them.

I understand you have issued two Regulation 28 reports. This response is prepared in solely in response to the Regulation 28 report addressed to NWAS (and others) in relation to the Joint Operating Protocol (JOP).

I note you have requested NWAS:-

Provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.

You have raised your concern having heard evidence relating to the preparation of a Joint Operating Protocol (JOP) between the North West Ambulance Service and the five regional police forces which stalled in July 2022 but was at an advanced stage of completion at the time of the inquest.

This Joint Operating Protocol was designed to improve communication between the North West Ambulance Service and the Police forces at all incidents including those involving drug overdoses. It addresses the issues of which emergency service should take responsibility for incidents and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can A31

escalate their concerns. For instance, this could be in relation to a person suspected to have taken a drug overdose.

As confirmed in the evidence provided by the Trust during the inquest, the JOP implementation process was recommenced with all Police partners on 6 July 2023 and involved fortnightly meetings with all parties. The aim of these meetings was to agree a standard format and wording for the JOP to be used across the North West.

On 12 October 2023, the JOP went live within NWAS in conjunction with Cheshire, Cumbria, Lancashire and Merseyside Police Forces. This version was not adopted by Greater Manchester Police and although discussions were still ongoing with them, it was considered important that the process and implementation was not delayed.

We have continued to work closely with Greater Manchester Police to overcome any remaining barriers and an updated version of the JOP has now been agreed with Greater Manchester Police who are in the final stages of sign off. It is anticipated the updated version of the JOP will be implemented and “go live” across the whole North West following the next meeting with police partners, scheduled for the latter part of February 2024.

Following the conclusion of the inquest, the Trust has also engaged with British Transport Police, North West Fire Control, Fire and Rescue Services from Lancashire, Greater Manchester, Cheshire and Cumbria and encouraged them to sign the JOP. Extending the JOP to include these partner agencies will bring additional benefits to the whole of the North West. British Transport Police and Merseyside Fire and Rescue have signed off the updated version of the JOP. North West Fire Control and Lancashire, GM, Cheshire and Cumbria Fire and Rescue Services are to review the document at the Operations Management Committee scheduled to take place in early February 2024.

I am grateful to you for highlighting your concern to me. Your concern has reaffirmed the need for joined up working and the importance of the Joint Operating Protocol. It has been extremely useful in driving forward the work outlined in this letter.

I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me or the Trust’s Assistant Director of Legal Services, Ms .

GMP Police / Law Enforcement

PDF

Noted

Response not parsable (AI summary)

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Merseyside Fire and Rescue Service Fire & Rescue Service

PDF

Noted

Merseyside Fire and Rescue Service states that its existing procedures for communicating casualty information to NWAS are sufficient, including written instructions and escalation options. (AI summary)

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Dear Sirs

Regulation 28 Report into the death of Claire Nicole Briggs

Upon receipt of the Regulation 28 referred to above Merseyside Fire and Rescue Service reviewed its current procedures and standards of communication with its blue light partners, in particular with North West Ambulance (‘NWAS’).

Whilst Merseyside Fire and Rescue Service (‘MFRS’) has a Memorandum of Understanding in place with NWAS for specific types of incidents for example a concern for welfare which details the actions of both parties there are also additional established procedures for communicating casualty information. There are written instructions employees must adhere to when relaying casualty information. This casualty information is transmitted in the following format.

• Gender

Date: 15th October 2024 A35

• Age – if unknown Incident Commander should confirm if child, youth, adult or elderly

• Level of consciousness, breathing and presence of pulse:

o Breathing and conscious o Breathing but unresponsive o Unresponsive, not breathing o Unresponsive, not breathing, no pulse

• Suffering from:

o Smoke inhalation – slight or severe o Bleeding – severity and location of bleed o Burns – severity and location of burns o Other injuries/condition

• Activity of MFRS crews:

o
e.g. giving CPR, administering oxygen, bleeding control, burns treatment, etc.

Operational crews on scene are instructed to note any changes in the condition of casualties and report these using the same format as above to MFRS Fire Control as soon as observations change. As well as this information being passed on to NWAS’s control room, the MFRS Fire Control will also relay back to crews on scene the estimated time of arrival for a NWAS resource. Where crews on scene feel that a swifter response is required they can escalate by asking MFRS Fire Control to contact the NWAS emergency operations centre direct and speak to the senior paramedic who can expedite an attendance if needed.

For situations where the casualty condition appears initially less serious there is also the option of providing a phone number to the emergency operations centre to allow a clinician to remote triage the casualty.

We believe the measures already in place are sufficient to prevent future deaths arising from the circumstances outlined in the Regulation 28 notice.

Lancashire Constabulary Police / Law Enforcement

PDF

Action Planned

Lancashire Police has agreed to Version 1.3 of a Joint Operating Protocol (JOP) with regional forces and NWAS to provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays; awaiting final sign-off from GMP and Fire and Rescue. (AI summary)

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Dear Mr Farrow,

In response to the Regulation 28 Report into the death of Claire Nicole Briggs sent to our Assistant Chief Constable on the 8th of December 2023, please see below response on behalf of Lancashire Police:

Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.

Lancashire Police are already working closely with North-West Regional Forces and North-West Ambulance Service in relation to agreed processes in the Joint Operating Protocol. The document will provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays. It will also give operational officers at the scene of an incident guidance and information to obtain direct clinical advice from Northwest Ambulance Service prior to them arriving on the scene of an incident. Implementation was initially via email/briefing to all Force Control Room Supervisors and Force Incident Managers.

Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from Northwest Ambulance Service who are leading on the document.

If you require any further detail, please do not hesitate to contact me.

Kind regards

.

Operations Manager - West Force Control Room HQ – Contact Management Lancashire Constabulary

m:

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Cheshire Constabulary Police / Law Enforcement

PDF

Action Taken

Cheshire Constabulary has signed the Joint Operating Protocol (JOP) with NWAS and supports its endorsement by other parties, with a coordination meeting scheduled for January 16, 2024. (AI summary)

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Dear Sir

I can confirm as follows in response to the Regulation 28 response for Cheshire Constabulary in connection with the Briggs inquest.

1. Cheshire Constabulary has been in liaison with NWAS and throughout the development of the JOP has been supportive and keen to move this forward.
2. In October 2023, we signed the original JOP, there were no barriers from us, although other parties have “rejected” the proposed JOP.
3. I have authorised for the revised JOP to now be signed and this has been completed by our Head of Public Contact on the final draft version dated 22/12/2023.
4. The document also includes several fire services, and British Transport Police. I am told they have not yet endorsed the policy but there is a meeting on 16th January 2024 for the coordination and the further signatories to meet and sign the document

Cheshire Constabulary are supportive of the report and have fully agreed to endorse the final draft.

From: Manchester South Coroner

Sent: Friday, December 8, 2023 5:27 PM To:

Cc: Subject: [EXTERNAL] RE: Claire Nicole Briggs (deceased) (ref: 28264272)

CAUTION: This email originated from outside of the organisation. Do not click links or open attachments unless you recognise the sender and know the content is safe. Time in diary on 4/1 – deadline for response is 2/2/24

Dear ACC Dutton,

Our case reference:

Please find attached a Regulation 28 Report for your attention.

Kind regards, Coroner's Officer A1

Contact us about this case

NOTE: Please do not edit the subject line when replying to this email.

Confidentiality:- This email, its contents and any attachments are intended only for the above named. As the email may contain confidential or legally privileged information, if you are not, or suspect that you are not, the above named or the person responsible for delivery of the message to the above named, please delete or destroy the email and any attachments immediately and inform the sender of the error. A2

Report sections

Investigation and inquest

On 29th November 2022 an investigation was commenced into the death of Claire Nicole Briggs, aged 42 years. The investigation concluded at the end of the inquest on 12th July 2023. The conclusion of the inquest was that she died of a propranolol overdose on 28th November 2022 at Stepping Hill Hospital, Stockport, having taken approximately propranolol tablets from previous prescriptions. She declined to be taken to hospital by the police for the critical time period after she had taken the tablets. There were 2 admitted failings by the North West Ambulance Service effectively to conduct clinical reviews of the incident which were not in themselves causative of her death, but the combined effect of those failings, the absence of any method within the NHS Pathways system to identify high risk overdoses and the pressures on the deployment of ambulances on that day combined to lead to a delay in her arrival at hospital which possibly contributed to her death.

Circumstances of the death

Claire Briggs was first prescribed propranolol from 2008 and had been regularly prescribed daily doses of that medication since 2019.

. I found, on the evidence, that she had consumed approximately propranolol tablets. A friend and the police attended at her home quickly. Ms Briggs was resistant to be taken to hospital until the time at which the effects of the ingestion of drugs became evident. Notwithstanding her stance, the police officers and others at the scene made repeated calls to the ambulance service. In total, 9 calls were made between 4.37pm and 6.12pm, 6 of which were made prior to Ms Briggs relenting and accepting that she should be taken to hospital and a further separate call by the police to the Hear and Treat helpline. The evidence I heard was that calls made by police officers from the scene to NWAS are triaged in the same way as other 999 calls. The ambulance service call handlers used the NHS Pathway process in dealing with each of the calls, which prompted a response category under the NHS Pathway system which resulted in a Category 3 response, which was not upgraded to Category 2 until a call made at 17.53 and the incident was prioritised at 18.16 so that the next available ambulance was allocated to respond. There were significant delays within the ambulance service at that time, such that national target response times were significantly breached. Prior to the arrival of the ambulance and in light of Ms Brigg’s obviously deteriorating condition and the uncertainty over the arrival time of the ambulance, the police officers decided to transport her to hospital themselves by police vehicle, but she experienced seizures before the police car left the vicinity of her address, which as closely followed by the arrival of the ambulance at 18.32. The police officers at the scene, in the calls they made from the scene and through their control room were unable to convey the seriousness of Ms Brigg’s condition to the ambulance service. She went into cardiac arrest at the scene in the back of the ambulance and was subsequently taken to hospital, where, despite care and treatment under guidance from a senior member of the National Poisons Advice Service, she died. The ambulance service accepted that there were failures to undertake timely clinical reviews of the incident.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0513
Date of report: 8 December 2023
Coroner: Adrian Farrow
Coroner area: Manchester South

Responses identified

Responses identified 13 of 13

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Feb 2024.

Sent to

British Transport Police

Cheshire and Merseyside Integrated Care Board

Cheshire Constabulary

Cumbria Constabulary

Greater Manchester Integrated Care Board

Greater Manchester Police

Lancashire and South Cumbria Integrated Care Board

Lancashire Constabulary

Lancashire Fire and Rescue Service

Merseyside Fire and Rescue Service

Merseyside Police

North West Ambulance Service

North West Fire Control

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.