South East Coast Ambulance Service
NHS / Health Body
Action Taken
SECAmb issued a "Hot Topic" learning update to all 111 call handling staff in October 2021, emphasising the need to identify and refer complex cases to clinicians and provided training and guidance to ensure staff fully understand the diverse needs of patients. (AI summary)
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Dear Madam Coroner Hannah Royle deceased I write in response to your Regulation 28 Prevention of Future Deaths report dated 4 October
2021. I was very much saddened to read of Hannah’s death and I would like to express my personal condolences to
Senior members of the 111-service management team have met to discuss the concerns you raised and how best to address them. We have also liaised with NHS England and NHS Digital in order to ensure that all parts of your report are answered by the most appropriate organisation. Addressing your concerns as numbered in your report: 1 & 2 – failure to recognise a complex case and transfer to a more senior member of staff Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken:
1. Work has been undertaken on a focused area of learning known as a “Hot Topic” which was issued to all call handling staff in the 111 service in October 2021. A copy is attached. NHS Pathways has been designed to triage a symptom in an otherwise well, non-complex patient
i.e. with no medical history and no medication issues. It will be noted that whilst there is no defined list of calls that are to be classified as complex, a wide range of circumstances could lead to the call being considered complex, including any patients with complex medical history or multiple unrelated symptoms, patients unable to prioritise a main symptom and patients who are unable to verbalise the answer to triage questions, for example those who are non-verbal.
2. Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability. A copy of the relevant part of the key skills course content is attached.
3. Health Advisors and Emergency Medical Advisors have a period of mentoring following their initial training and also if any concerns are recognised during routine or requested audits. In order to pass the mentoring process, they have to demonstrate that they have passed all key competencies. This is achieved by a mentor witnessing the mentee undertake all of the required elements from within the mentoring pack to the required standard. The mentor will then sign off on the individual elements once competency is achieved. The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.
In addition to the actions already undertaken, the following is planned:
4. A “shared learning” is an anonymised real case example circulated to all relevant staff to demonstrate an issue in practice and to reinforce theoretical learning. Experience has shown that real cases can be more powerful and thus are more readily retained than theory of a particular process or procedure. Our Head of Governance for 111 plans to publish a shared learning based on Hannah’s family’s contacts with the 111 service before the end of January
2022.
It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.
3 - The skill and experience of the clinical advisor
The NHS Pathways licence contains a definition of a Clinician who may give clinical advice as part of the NHS Pathways system as follows:
"Clinician" means either: (a) a registered nurse; or (b) a registered paramedic; or (c) any other personnel with an appropriate recognised clinical qualification as authorised and notified to End Users by the Authority from time to time, and which is selected by the End User to receive the necessary training to enable them to perform the role detailed in schedules 1 and 2;
As (in most cases) it is SECAmb who employs the clinician, we remain responsible for setting criteria for employment by way of a Job Description, for setting standards of skill, experience and qualification for recruitment and for ensuring that clinicians are trained in the use of the NHS Pathways system. We also have a licence obligation to audit and manage the performance of the clinicians we employ.
Governing bodies such as the Nursing and Midwifery Council set requirements for their registrants to demonstrate, on an annual basis, that their clinical practice is up to date.
SECAmb require applicants for the Clinical Advisor role to have at least two years’ post qualification or relevant experience as part of the recruitment process. SECAmb shortlists candidates in line with a robust set of criteria. Once candidates have been shortlisted, they are invited to interview/assessment.
This consists of the following:
• Clinical Questions paper. These questions cover a range of conditions, complaints and treatments and is a pass/fail element.
• Clinical Scenarios. The candidate has to pass two scenario type questions, which again are based on a variety of different conditions and symptoms.
• Once the candidate passes the first two elements, they have to pass a competency-based interview.
Once a candidate has been successful they must complete all the required training to be signed off as a Clinical Advisor. This training consists of the following:
• NHSP and Computer Aided Dispatch (CAD) course. This is a pass or fail course and is a national requirement.
• Each candidate must complete the call handling module to ensure that they are competent in using the system.
• Each candidate must complete ‘soft’ audits prior to being moved on to the next phase of training.
• Each candidate must then complete a period of clinical mentoring.
• Each candidate must complete five sign off audits before being signed off to work as a solo Clinical Supervisor.
All staff using NHSP are then required to receive 3 to 5 audits a month. The number of required audits relate to which audit tier they are on. The tier a staff member is on is dependant on experience and also whether they are on any improvement plan.
SECAmb does not specify a field of experience such as A&E or urgent care because the range of medical conditions and situations with which we deal on a daily basis is so wide. Experience in a wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental health) helps us to accommodate the extremely diverse needs of our patients.
In autumn 2020, SECAmb entered into a contract to provide a Clinical Assessment Service (“CAS”). The CAS is a national framework whereby 111 providers are required to employ a range of various clinical skill sets to cater for various patient needs in a virtual environment. The CAS incorporates clinicians from a very wide range of disciplines including GPs, midwives, registered Mental Health nurses, Paediatric Nurses and others; the number of clinicians and range of disciplines is increasing on a monthly basis. The objective of the CAS in the longer term is to
provide a system whereby patients are directed to the most appropriate service to accommodate their needs; that service may be provided by the SECAmb CAS virtually or by an onward care provider. This system aims to get patients the most appropriate help within the most appropriate time frame, with the patient only needing to make one phone call to 111. This all makes for a better patient journey as the service aims to meet their health care needs without them requiring to have multiple contacts with various services. As our complement of clinicians increases in both number and diversity, it is anticipated that the bespoke and specialist nature of the 111 service will increase accordingly.
4 & 5 – role and understanding of the 111 service; naming of Health Advisors
As these are matters of national policy, SECAmb defers to NHS England.
6 – NHS Pathway for Abdominal Pain
We defer to NHS Digital on this matter.
I trust that this response provides assurance that SECAmb have promptly addressed the matters within our remit and have plans to further enhance our staff’s understanding of and compliance with our complex call procedure.
If I can be of further assistance to you or to , please do not hesitate to contact me.
2021. I was very much saddened to read of Hannah’s death and I would like to express my personal condolences to
Senior members of the 111-service management team have met to discuss the concerns you raised and how best to address them. We have also liaised with NHS England and NHS Digital in order to ensure that all parts of your report are answered by the most appropriate organisation. Addressing your concerns as numbered in your report: 1 & 2 – failure to recognise a complex case and transfer to a more senior member of staff Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken:
1. Work has been undertaken on a focused area of learning known as a “Hot Topic” which was issued to all call handling staff in the 111 service in October 2021. A copy is attached. NHS Pathways has been designed to triage a symptom in an otherwise well, non-complex patient
i.e. with no medical history and no medication issues. It will be noted that whilst there is no defined list of calls that are to be classified as complex, a wide range of circumstances could lead to the call being considered complex, including any patients with complex medical history or multiple unrelated symptoms, patients unable to prioritise a main symptom and patients who are unable to verbalise the answer to triage questions, for example those who are non-verbal.
2. Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability. A copy of the relevant part of the key skills course content is attached.
3. Health Advisors and Emergency Medical Advisors have a period of mentoring following their initial training and also if any concerns are recognised during routine or requested audits. In order to pass the mentoring process, they have to demonstrate that they have passed all key competencies. This is achieved by a mentor witnessing the mentee undertake all of the required elements from within the mentoring pack to the required standard. The mentor will then sign off on the individual elements once competency is achieved. The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.
In addition to the actions already undertaken, the following is planned:
4. A “shared learning” is an anonymised real case example circulated to all relevant staff to demonstrate an issue in practice and to reinforce theoretical learning. Experience has shown that real cases can be more powerful and thus are more readily retained than theory of a particular process or procedure. Our Head of Governance for 111 plans to publish a shared learning based on Hannah’s family’s contacts with the 111 service before the end of January
2022.
It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.
3 - The skill and experience of the clinical advisor
The NHS Pathways licence contains a definition of a Clinician who may give clinical advice as part of the NHS Pathways system as follows:
"Clinician" means either: (a) a registered nurse; or (b) a registered paramedic; or (c) any other personnel with an appropriate recognised clinical qualification as authorised and notified to End Users by the Authority from time to time, and which is selected by the End User to receive the necessary training to enable them to perform the role detailed in schedules 1 and 2;
As (in most cases) it is SECAmb who employs the clinician, we remain responsible for setting criteria for employment by way of a Job Description, for setting standards of skill, experience and qualification for recruitment and for ensuring that clinicians are trained in the use of the NHS Pathways system. We also have a licence obligation to audit and manage the performance of the clinicians we employ.
Governing bodies such as the Nursing and Midwifery Council set requirements for their registrants to demonstrate, on an annual basis, that their clinical practice is up to date.
SECAmb require applicants for the Clinical Advisor role to have at least two years’ post qualification or relevant experience as part of the recruitment process. SECAmb shortlists candidates in line with a robust set of criteria. Once candidates have been shortlisted, they are invited to interview/assessment.
This consists of the following:
• Clinical Questions paper. These questions cover a range of conditions, complaints and treatments and is a pass/fail element.
• Clinical Scenarios. The candidate has to pass two scenario type questions, which again are based on a variety of different conditions and symptoms.
• Once the candidate passes the first two elements, they have to pass a competency-based interview.
Once a candidate has been successful they must complete all the required training to be signed off as a Clinical Advisor. This training consists of the following:
• NHSP and Computer Aided Dispatch (CAD) course. This is a pass or fail course and is a national requirement.
• Each candidate must complete the call handling module to ensure that they are competent in using the system.
• Each candidate must complete ‘soft’ audits prior to being moved on to the next phase of training.
• Each candidate must then complete a period of clinical mentoring.
• Each candidate must complete five sign off audits before being signed off to work as a solo Clinical Supervisor.
All staff using NHSP are then required to receive 3 to 5 audits a month. The number of required audits relate to which audit tier they are on. The tier a staff member is on is dependant on experience and also whether they are on any improvement plan.
SECAmb does not specify a field of experience such as A&E or urgent care because the range of medical conditions and situations with which we deal on a daily basis is so wide. Experience in a wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental health) helps us to accommodate the extremely diverse needs of our patients.
In autumn 2020, SECAmb entered into a contract to provide a Clinical Assessment Service (“CAS”). The CAS is a national framework whereby 111 providers are required to employ a range of various clinical skill sets to cater for various patient needs in a virtual environment. The CAS incorporates clinicians from a very wide range of disciplines including GPs, midwives, registered Mental Health nurses, Paediatric Nurses and others; the number of clinicians and range of disciplines is increasing on a monthly basis. The objective of the CAS in the longer term is to
provide a system whereby patients are directed to the most appropriate service to accommodate their needs; that service may be provided by the SECAmb CAS virtually or by an onward care provider. This system aims to get patients the most appropriate help within the most appropriate time frame, with the patient only needing to make one phone call to 111. This all makes for a better patient journey as the service aims to meet their health care needs without them requiring to have multiple contacts with various services. As our complement of clinicians increases in both number and diversity, it is anticipated that the bespoke and specialist nature of the 111 service will increase accordingly.
4 & 5 – role and understanding of the 111 service; naming of Health Advisors
As these are matters of national policy, SECAmb defers to NHS England.
6 – NHS Pathway for Abdominal Pain
We defer to NHS Digital on this matter.
I trust that this response provides assurance that SECAmb have promptly addressed the matters within our remit and have plans to further enhance our staff’s understanding of and compliance with our complex call procedure.
If I can be of further assistance to you or to , please do not hesitate to contact me.