Adam Stone

Dear Miss Brown

REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS: ADAM STONE

I am writing in response to the Regulation 28 report to prevent future deaths following the inquest into the death of Adam Stone which you issued on 27 January 2022 to the Association of Ambulance Chief Executives (AACE). I am the managing director of AACE, and I have consulted with my medical colleagues to inform this response.

AACE is a formally constituted private company wholly owned by the English and Welsh Ambulance NHS Trusts who are all full voting members. Its primary focus is the ongoing development of the UK ambulance sector and the improvement of patient care. It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines.

You have suggested that action is taken to prevent future deaths and requested that the AACE consider matters of concern in relation to the categorisation of calls to suspected ABD. Your matter of concern is that the continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk.

We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response. This is a position AACE support - a decision arrived at following work we conducted looking specifically at ABD which was prompted as a result of other Coroner’s enquiries regarding which category of response someone presenting as possible ABD should receive.

To help inform this decision and provide evidence, a joint police and ambulance review was conducted in the north of England between one ambulance service and a police force for a period of 9 months between August 2019 to May 2020. The purpose of the joint review was to establish whether individual presenting features in patients who were identified by police officers on scene as possible ABD, might individually or in combination reliably identify an increased risk of clinical deterioration associated with increased mortality and to determine the most appropriate ambulance response time category. Police officers identified 28 potential ABD cases in the nine-month review period, representing 1% of the mental health or behavioural crisis 999 calls attended by the police

force. The review concluded that for patients who had been recognised as presenting with symptoms and signs of possible ABD, a Category 2 ambulance response was appropriate, if there was information that there were immediately life-threatening signs present, the patient should then receive a Category 1 ambulance response. The evidence and recommendations were accepted through the ECPAG process and implemented by all the UK ambulance services.

We agree that ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of agitation with likely physiological abnormalities, caused by one of a number of possible toxicological, physical, or mental health conditions. In the prehospital setting we are often unable to ascertain the exact cause of the presentation while providing clinical care prior to arrival at an emergency department. We considered whether the use of restraint alone should warrant an automatic Category 1 response, but this was agreed through the ECPAG process as not appropriate unless immediately life-threatening signs were present. An ambulance may be diverted away from someone having for example, a heart attack, stroke, or similar condition presenting with life-threatening features, if other conditions are automatically prioritised as Category 1 without similar clinical features.

We would like to highlight other work we have undertaken and continue to undertake around ABD. We have developed and issued national clinical guidance in 2019, then updated in 2020, to UK ambulance clinicians. We have also supported education and presented at national conferences and webinars for police and ambulance staff, and we are continuing to develop further guidance around managing patients with extreme agitation.

I hope that you will feel the work we have done nationally to consider the issues you have raised explains the current system for responding all our patients including those with suspected ABD. We are absolutely committed to learning from all adverse events and doing everything within our power to prevent them happening again in the future.

We would also like to extend our sincere condolences to the family of Mr Stone.

If we may be of further assistance, please do not hesitate to contact us.

Dear Madam Coroner,

Inquest touching upon the death of Adam Marshall Elliot Stone

I write in response to your Regulation 28 Report To Prevent Future Deaths (“PFD”) dated 27 January
2022. I was very sorry to learn of the death of Mr Stone and, on behalf of the College of Paramedics, I would like to extend my sincere condolences to his family and friends.

The College of Paramedics is the recognised professional body for all paramedics, including those who operate within the ambulance sector in the UK. We are established as a charity, with the charity’s objects being the “advancement of health and saving and improving of lives and the advancement of education, training and efficiency within the paramedic profession”. Essentially, the College represents its members in all matters affecting their clinical practice and we support members to achieve the highest standards of patient care.

It may assist for me to clarify that the College of Paramedics is not responsible for setting standards for paramedics’ education, training, or practice. That responsibility lies with the statutory regulator of paramedics, the Health and Care Professions Council (HCPC). However, the College of Paramedics will ensure that any subsequent review of its pre-registration curricula will include the latest evidence on Acute Behavioural Disturbance.

The College of Paramedics is also not responsible for determining NHS ambulance response categories. That power lies with NHS England, although the Association of Ambulance Chief Executives (AACE) provide evidence and guidance to support this.

In these circumstances, I regret that I do not believe it is within the College’s power to implement any particular action in response to your PFD.

I am aware that AACE will also be writing to you in response to your PFD. The College endorses the content of AACE’s letter to you. However, the College would always support an evidence-based review of the current response categorisation of Acute Behavioural Disturbance in order to ensure that a Category 2 response remains the appropriate disposition and I will share this correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose that such a review be considered in the light of this PFD.

The College of Paramedics has also been involved in collaboration with AACE on the recognition and treatment of Acute Behavioural Disturbance, including this topic being presented at recent Continuous Professional Development (CPD) events following extensive guideline development.

Please do not hesitate to contact me if you feel that the College can be of any further assistance with this matter.

Dear Miss Brown NHS Digital Response to Regulation 28 Report – inquest touching the death of Adam Marshall Elliot Stone I am writing in response to the Regulation 28 Prevention of Future Deaths report received from HM Area Coroner dated 27th January 2022. This follows the death of Adam Stone who sadly passed away on 12th September 2019. This was followed by an investigation and inquest which concluded on 25th January 2022. Firstly, I would like to offer my sincerest condolences to Adam’s family. NHS Digital were not aware that this inquest was occurring, and therefore we did not have the opportunity to provide information to assist your inquiry. I am Dr , and I am writing in my capacity as Chief Clinical Officer, NHS Pathways, NHS Digital. NHS Pathways is the clinical decision support software (CDSS) used by all 111 service providers, and some 999 ambulance trusts in England. For information, we have included a short summary of the functions that NHS Pathways performs and the governance that underpins it (containing background information on NHS Pathways) in Appendix A.

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In response to the matters of concern outlined in the report:

1. Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation which usually includes abnormal physiology and/or behaviour. ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of aggression and agitation with physiological abnormalities, often associated with a cause (drugs, mental health disturbance or medical condition). The term has been adopted by most healthcare providers in the UK. The presenting behaviour can range from mildly erratic, to a state of extreme agitation, and physical exertion. Patient has signs of sympathetic autonomic dysfunction, such as significant tachycardia, marked metabolic acidosis and hyperthermia. These are associated with multi organ failure and death. The incidence of sudden death is sometimes quoted as 10% although some studies suggest a much higher rate and current research is not sufficient to rely on this figure. Police Forces and Emergency Departments regard ABD as a medical emergency because of the risk of sudden death.

Comments noted.

2. ABD has no specific antidote or treatment as it is the underlying cause that needs to be identified and treated. However, the main principles of treatment are to calm the patient, cool them down and provide supportive treatment as much as possible, whilst maintaining safety for both the patient and the care providers. Sometimes de- escalation cannot be achieved, and restraint is required in the interests of the patient, members of the public and carers. Physical restraint should always be kept to a minimum because resistance to it increases the physiological burden to the patient and therefore the risk of death. Chemical restraint, sedation, is rarely available outside hospital. Therefore, the key to successful treatment of severe ABD is getting the patient to hospital as soon as possible to avoid or minimise restraint. Comments noted.
3. Currently NHS Pathways, which is used by West Midlands Ambulance Services, categorises ABD (or Excited Delirium as it can also be called) as requiring a category 2 response. A category 2 response has a mean average response time of 18 minutes from categorisation of the call up to a maximum of 240 seconds from the start of the call. It is understood from the evidence that the other triaging tool used by Ambulance services in the UK, Advanced Medical Priority Dispatch (AMPDS), also gives ABD/Excited Delirium a category 2 priority.

NHS Pathways is a triage system that assesses symptoms presented at the time of a call and directs patients to the most appropriate services based on their described symptoms. It does not provide a suggested diagnosis or rely on call handlers being able to recognise particular conditions.

Calls from members of the public ABD (also known as Excited Delirium) is not a condition the general public are familiar with. Therefore, in respect of calls from the public, a specific disposition for ABD will not be provided, even if declared by the caller, but rather the symptoms described will be triaged.

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Any call from a member of the public will undergo an initial assessment for immediate life- threatening symptoms, including whether the patient has stopped breathing, is choking, is having a fit or seizure, is unconscious, has heavy blood loss, is experiencing severe breathing difficulty or a life-threatening allergic reaction. If any of these life-threatening symptoms are identified, then they receive a disposition which is mapped to a Category 1 ambulance response. Should no immediately life-threatening symptoms be identified, then the assessment progresses through further questions to establish an appropriate outcome for the clinical condition of the patient.

Calls from Healthcare Professionals Calls which are received from healthcare professionals are dealt with by a different route to the general public. For calls received from a healthcare professional, there are initial questions about emergency symptoms and those relating to threatened loss of life, limb or sight. If answered ‘no’, there is then a question about mental health emergencies, which means an emergency ambulance may be required. These questions include determining whether the patient is under active restraint or in need of restraint, or whether ABD has been declared. If any of these situations apply, they receive a disposition which is mapped to a Category 2 ambulance response.

Calls from Police Officers Calls from the Police are managed in two different ways, depending on whether the patient is with the caller. If the caller is with the patient, then a symptom-based assessment can be undertaken in the same way as if the caller was a member of the public. However, when the caller is not with the patient, it is usually not possible to complete the assessment due to a lack of available information and therefore a route called ‘early exit’, for a ‘remote observer’ is taken.

This includes questions on life-threatening symptoms, as described above. If immediately life- threatening symptoms are identified, at any stage, then a disposition is reached which is mapped to a Category 1 ambulance response.

If there are no immediately life-threatening symptoms further questions are asked to identify severe and time sensitive issues, including whether ABD has been declared. Any declaration of this will result in a disposition mapped to a Category 2 ambulance response.

Ambulance Responses The above reflect the national ambulance frameworks embedded within NHS Pathways. People who have undergone restraint or had ABD declared by the Police or a healthcare professional require a Level 2 response, mapping to the Category 2 ambulance response standard. These frameworks were jointly developed by the Association of Ambulance Chief Executives (AACE) and NHS England, with clinical support from NHS Digital. The national ambulance frameworks are owned by NHS England:

responses-framework/

NHS England, via its Emergency Call Prioritisation Advisory Group (ECPAG), determines the category of ambulance response required for a given triage code and/or clinical condition based upon advice received from the Clinical Coding Review Group (CCRG) – also a function of NHS England and chaired by an Ambulance Medical Director – and by the National Ambulance

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Medical Director’s group (NASMeD), a sub-function of AACE. NHS Digital has representation within CCRG and ECPAG to help inform their decisions.

Within NHS Pathways, in respect of requests for assistance from the police, prisons and healthcare professionals, the triage coding for ABD maps to the nationally agreed Category 2 ambulance response standard, as instructed by ECPAG.

We are unable to comment on the process used by AMPDS.

4. The inquest heard evidence from 2 expert witnesses, Dr a Consultant in Emergency Medicine and a Medical Examiner at Poole General Hospital who sees several cases of severe ABD a year within his clinical practice, and Dr

a Consultant in Emergency and Intensive Care Medicine and a Clinical Toxicologist at Barts Health NHS Trust in London. Dr was one of the authors of the Royal College of Emergency Medicine's Guidelines on ABD and deals with cases of ABD every few days in clinical practice. Both experts gave evidence that, in their opinion, severe ABD should be given the highest priority by Ambulance Services. Dr explained that this was his view because, even though category 1 is reserved for patients in cardiac arrest or peri arrest, ABD is unique in that it is so difficult for any effective treatment or management to be given outside of hospital to prevent catastrophic deterioration and death, and, in fact, the often necessary intervention of restraint whilst awaiting an ambulance actually increases the risk. Dr view was that if an effective system was used to identify ABD it would not create an undue burden on Ambulance Services as it is not a common occurrence. Dr was in agreement with Dr but did feel that there should be some assessment of severity as mild cases of ABD do not create the risk of death that warrants the category 1 response. Dr evidence was that restraint could be used as the trigger for a designation of category 1 for ABD given that the need for restraint both indicates that the case is severe and is actually increasing the risk of death.

The range of symptoms associated with more common emergency medical presentations and the unknown, though believed to be rare, incidence of ABD presents challenges for telephone triage and the appropriate level of emergency response. Ambulance resources are finite; Category 1 responses typically result in a robust operational resource by the ambulance service, sometimes activating specialist critical care resources and often drawing clinical resources away from other emergencies. As a result, there should be a high degree of certainty that a Category 1 response is actually required.

During the period 2020-21 an AACE led ‘task and finish’ group, chaired by a senior medical representative from NASMeD, and attended by NHS Digital, considered the appropriateness of a Category 1 response to ABD following a request for emergency medical assistance from the Police. The evidence reviewed, including the results of a pilot conducted by the Yorkshire Ambulance Service with South Yorkshire Police, did not support a Category 1 response. The task and finish group presented to CCRG, and subsequently to ECPAG, a recommendation that suspected ABD reported by the Police should be responded to as a Category 2 response. ECPAG approved this recommendation in September 2021.

Therefore, any change in ambulance response categorisation would be matters for the respective

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NHS England and AACE groups to consider, and would need to be approved by ECPAG as a function of NHS England.

5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk. We would like to reassure you that NHS Pathways recognises the risks associated with ABD/ Excited Delirium and also that restraint may be a factor contributing to a patient’s deterioration. As described above, NHS Pathways is fully compliant with the national ambulance response standard mandated by ECPAG for suspected ABD, with regard to healthcare professionals and Police requests for medical assistance. NHS Digital will continue to work collaboratively with our stakeholders in the ambulance sector, and under the direction of ECPAG, on the subject of ABD as new evidence arises.

In 2019, NHS Pathways produced “Spotlight on: ABD” training materials to be used by call assessors and clinicians with the 999 emergency operation centres of ambulance services that use the NHS Pathways system. This was published to raise awareness of ABD as a rare but very serious medical condition which warrants an emergency response.

If I can be of any further assistance, please let me know.