Rashdah Bhatti

Dear Mr Gittins, Re: Rashdah Waseem Begum Bhatti I write in response to the Prevention of Future Deaths Report issued to this Trust on 12 September 2023, following the inquest in relation to Rashdah Waseem Begum Bhatti. The matters of concern that you have asked the Trust to consider are: “The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object”

Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased.

Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway.”

The Medical Priority Dispatch System™ (MPDS®) establishes a universal standard for emergency dispatchers taking calls for a broad range of triage response which may include drowning, stabbing, gunshot wounds, and much more. Tested over hundreds of millions of calls since 1979, MPDS includes 36 protocols that are continually updated as per recommendations and research made by specialist medical professionals and associations. Accredited Centre of Excellence (ACE) designation is reserved for high-performing agencies that consistently achieve excellence. It is a distinguished award for those who cultivate a centre wide pride, teamwork, and innovation by putting their communities first. I also attach for your reference copies of WAST ACE Performance standard data and the Agency Performance Benchmark, both providing details of the MPDS audits undertaken over a 24-month period. These documents illustrate that the Trust is performing to an ACE level in relation to all aspects of our call handling. The audits include a review of the Post-Dispatch Instructions (PDIs) which includes the advice that should have been given with regard to Mrs Bhatti’s leg. Whilst referred to as “Post-Dispatch instructions”, these instructions are given at the time of the call, whether a resource has been dispatched or not. I also attach a copy of the MPDS call audit data, for audits completed in the last 24 months in relation to protocol 21(Haemorrhage/laceration). As you will see from that data (WAST Agency Performance document), of the 363 PDIs audited, errors occurred on 16 occasions. During October 2023 we undertook a focused audit of calls in relation to protocol 21(Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.