West Midlands Ambulance Service
NHS / Health Body
Noted
West Midlands Ambulance Service acknowledges the concerns and explains that they use NHS Pathways for triage, as required by Department of Health guidelines. They also describe their clinical validation team's review of category 3 and 4 patients and regular clinical audits. (AI summary)
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Dear Ms Serrano
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Diane Finch (Deceased)
Thank you for your email dated 15 May 2023 attaching your Regulation 28 Report.
Firstly, I am sorry that you have had to raise concerns with West Midlands Ambulance Service University NHS Foundation Trust (WMAS) following the inquest of Mrs Finch. Can I please take this opportunirty to pass on my sincere condolences to the family of Mrs Finch.
Please see our response to your concerns.
Concern 1 That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly.
Response
The Department of Health guidelines require UK ambulance Trusts to use one of two triage tools approved for assessing 999 ambulance calls. West Midlands Ambulance Service University NHS Foundation Trust triage all 999 calls using NHS Pathways. NHS Pathways determines the most appropriate level of care for the presenting symptoms during the call. Patients requiring an emergency ambulance are triaged into four categories, with an associated mean average response timeframe for each. The symptom groups within those categories are determined by the Clinical Coding Review Group, consisting of senior representation from all UK ambulance trusts.
The ambulance response categories and timeframes (hh:mm:ss) are:
Category 1 (00:07:00): A time critical, life-threatening event needing immediate intervention or resuscitation. For example, cardiac or respiratory arrest, airway obstruction, ineffective breathing, and unconsciousness with abnormal noisy breathing.
Category 2 (00:18:00): Potentially serious conditions that may require rapid assessment, urgent on scene intervention and or urgent transportation. For example, stroke, heart attack, severe blood loss and trauma.
Category 3 (01:00:00): An urgent problem that needs treatment to relieve suffering and transportation, or assessment and management on scene, or assessment, treatment, and referral to an alternative care provider where necessary within a clinically appropriate timeframe. For example, conscious patients presenting with a medical emergency, traumatic injuries, to include falls.
Category 4 (90th percentile 03:00:00): Problems that are not urgent, may be managed within the home (see & treat) or may require transport within a clinically appropriate timeframe. For example, falls with no declared injury.
When reviewing the 999 call made by Mrs. Finch, a higher response category would not have been generated without further clinical intervention. Mrs. Finch was conversant and advising her blood sugars were probably high due to being a type 1 diabetic. When asked, Mrs. Finch was unable to test her blood glucose level due to being unable to locate her testing kit, she was struggling generally with day-to-day activities and felt sleepy. The call assessor advised Mrs. Finch that she may receive a call back from a clinician for further assessment.
Concern 2 That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.
Response
In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, lead to the clinical validation team becoming a substantiated process within the Trust.
All category 3 and 4 incidents, except for a predefined list of exemptions now go directly to the clinical validation team. The team undertake a clinical triage, supported by the NHS Pathways triage tool for clinicians, to determine the most appropriate outcome for the patient based upon their clinical knowledge and experience. Outcomes range from a higher ambulance response category, referrals into urgent and community services, and self-care advice. By appropriately reducing the requirements for emergency ambulances, this supports greater availability of emergency resources to those patients with the most acute needs.
All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily.
The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.
All clinicians, and the clinical navigators, receive regular clinical audit to ensure competency, and safe and appropriate outcomes for patients. Audit is a requirement of NHS Pathways licensing agreement and provides learning opportunities for both the individual clinician and the Trust. All serious incidents and concerns raised regarding the appropriateness of a clinical triage receive audit and senior review.
Throughout 2023-23, the clinical validation team reviewed 179,695 category 3 and 4 patients. 64% of patients were referred to alternative services or provided with self-care advice to manage their symptoms at home. When reviewing the last 6 months to May 2023, only 9.9% of patients referred to alternative services or given self-care advice recontacted the Trust through 999. Often, the reason for recontacting was due to a failed referral pathway and not through worsening symptoms.
May I once again please pass on my sincere condolences to the family of Mrs Finch.
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Diane Finch (Deceased)
Thank you for your email dated 15 May 2023 attaching your Regulation 28 Report.
Firstly, I am sorry that you have had to raise concerns with West Midlands Ambulance Service University NHS Foundation Trust (WMAS) following the inquest of Mrs Finch. Can I please take this opportunirty to pass on my sincere condolences to the family of Mrs Finch.
Please see our response to your concerns.
Concern 1 That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly.
Response
The Department of Health guidelines require UK ambulance Trusts to use one of two triage tools approved for assessing 999 ambulance calls. West Midlands Ambulance Service University NHS Foundation Trust triage all 999 calls using NHS Pathways. NHS Pathways determines the most appropriate level of care for the presenting symptoms during the call. Patients requiring an emergency ambulance are triaged into four categories, with an associated mean average response timeframe for each. The symptom groups within those categories are determined by the Clinical Coding Review Group, consisting of senior representation from all UK ambulance trusts.
The ambulance response categories and timeframes (hh:mm:ss) are:
Category 1 (00:07:00): A time critical, life-threatening event needing immediate intervention or resuscitation. For example, cardiac or respiratory arrest, airway obstruction, ineffective breathing, and unconsciousness with abnormal noisy breathing.
Category 2 (00:18:00): Potentially serious conditions that may require rapid assessment, urgent on scene intervention and or urgent transportation. For example, stroke, heart attack, severe blood loss and trauma.
Category 3 (01:00:00): An urgent problem that needs treatment to relieve suffering and transportation, or assessment and management on scene, or assessment, treatment, and referral to an alternative care provider where necessary within a clinically appropriate timeframe. For example, conscious patients presenting with a medical emergency, traumatic injuries, to include falls.
Category 4 (90th percentile 03:00:00): Problems that are not urgent, may be managed within the home (see & treat) or may require transport within a clinically appropriate timeframe. For example, falls with no declared injury.
When reviewing the 999 call made by Mrs. Finch, a higher response category would not have been generated without further clinical intervention. Mrs. Finch was conversant and advising her blood sugars were probably high due to being a type 1 diabetic. When asked, Mrs. Finch was unable to test her blood glucose level due to being unable to locate her testing kit, she was struggling generally with day-to-day activities and felt sleepy. The call assessor advised Mrs. Finch that she may receive a call back from a clinician for further assessment.
Concern 2 That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.
Response
In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, lead to the clinical validation team becoming a substantiated process within the Trust.
All category 3 and 4 incidents, except for a predefined list of exemptions now go directly to the clinical validation team. The team undertake a clinical triage, supported by the NHS Pathways triage tool for clinicians, to determine the most appropriate outcome for the patient based upon their clinical knowledge and experience. Outcomes range from a higher ambulance response category, referrals into urgent and community services, and self-care advice. By appropriately reducing the requirements for emergency ambulances, this supports greater availability of emergency resources to those patients with the most acute needs.
All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily.
The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.
All clinicians, and the clinical navigators, receive regular clinical audit to ensure competency, and safe and appropriate outcomes for patients. Audit is a requirement of NHS Pathways licensing agreement and provides learning opportunities for both the individual clinician and the Trust. All serious incidents and concerns raised regarding the appropriateness of a clinical triage receive audit and senior review.
Throughout 2023-23, the clinical validation team reviewed 179,695 category 3 and 4 patients. 64% of patients were referred to alternative services or provided with self-care advice to manage their symptoms at home. When reviewing the last 6 months to May 2023, only 9.9% of patients referred to alternative services or given self-care advice recontacted the Trust through 999. Often, the reason for recontacting was due to a failed referral pathway and not through worsening symptoms.
May I once again please pass on my sincere condolences to the family of Mrs Finch.
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.