London Ambulance Service NHS Trust
NHS / Health Body
Action Taken
LAS and LAA will publish a bulletin on their intranet and share it with clinical staff and partner universities, reinforcing the importance of SBAR handovers and how to prompt them, and incorporating this into core skills refresher training. (AI summary)
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Dear Madam Regulation 28; Prevention of Future Deaths Report (PFD) arising from the inquest into the death of Nadeem AHMED Thank you for your Regulation 28 Report dated 8th July 2021 setting out your recommendations for consideration. You have requested that the LAS and LAA work together to improve our communication and address this through joint training for our staff. This response is prepared on behalf of both London Ambulance Service NHS Trust (LAS) and London’s Air Ambulance (LAA) working in partnership to discuss your concerns and having agreed a joint approach to address these. It is important to note that London’s Air Ambulance is a service delivered as a partnership between London’s Air Ambulance Charity, Bart’s Health NHS Trust and the London Ambulance Service. We would like to begin by expressing our sincere condolences to the family of Mr Ahmed. The LAS has worked in partnership with LAA for over 30 year and the very core of this relationship is centred on how the team from LAA are tasked to appropriate patients. This needs to be viewed in the context of the volume of emergency calls, which are received by the LAS each day, now regularly over 7000 calls per day. It is vital that the LAA team is specifically dispatched to the most unwell trauma patients in London. The fundamental tenet of how we task the team(s) from LAA is that the dispatch process is clinically lead and both the LAS and LAA are absolute in that this provides the best opportunity to ensure we target the valuable
LAA resources to patients in greatest need. This is not an easy or straightforward task when there are many thousands of calls to review, with each call requiring prompt and appropriate clinical triage and assessment. Monitoring all potentially relevant 999 calls coming in presents a challenge and ultimately means that some degree of clinical judgement is required based on the information that is obtained from the caller as well as the clinicians on scene. Over the last 30 years, we have developed a staged model of dispatch this is based around three levels of dispatch: (1) Immediate; this is a small cohort of cases where evidence tells us that without further information LAA skills may be required on scene and if available LAA are immediately dispatched. This includes cases such as a person struck by a train or a patient falling more than 20ft. (2) Interrogation; this is where further information needs to be gained from the 999 caller before a decision to dispatch can be made. This can be a silent process where the LAA paramedic in the operations centre listens to the 999 call for additional information that may be provided by the caller, or this can be an active process where the clinician speaks directly with the 999 caller to gain further information to inform the dispatch decision once the initial 999 call is complete. (3) Crew/Clinician request; this is where the attending ambulance clinician who arrives on scene either is asked to provide a clinical update or they directly request the attendance of the team from LAA. These processes are embedded with the Standard Operating Procedures for LAA and through the major trauma networks there are processes in place to ensure that we monitor cases, which may have benefited from the attendance of the enhanced care team from LAA and one was not sent. These are fed back through the LAS to the lead flight paramedic for review. These are very rare. Over the last three years we have further enhanced the ability for interrogation of calls with the use of video triage. Video triage is utilised through the Good Sam software, which allows, with the appropriate permissions, the clinician to view the incident using the camera on the callers’ phone. This technology can also be used to further inform the clinical report provided by the ambulance clinicians on scene. The SBAR (Situation, Background, Assessment, Recommendation) acronym is an established tool within the LAS and is used nationally within healthcare to minimise the risk of key information being missed when a handover is provided. This format is also used by our staff when handing over patients at hospital or when passing information to other clinicians such as GPs to promote best practice in clinical decision making via discussion. As we move forward we have been explicit that the SBAR tool should be used when providing a clinical handover to either the LAA paramedic or Advanced Paramedic Practitioner (or any other clinician) in the operations centre, to ensure the decision on deployment of an advanced clinical resource can be properly considered.
The SBAR tool was developed by the National Patient Safety Agency. The SBAR handover is designed to provide a structure for passing clinical information which is reproducible and aims to minimise risk of either incomplete information being passed or this being misinterpreted due to the ‘human factors’ experienced in a high pressure clinical situation. To provide further assurance around the information which is passed from clinicians on scene to inform the dispatch of further specialist resources we will expand the use of the SBAR handover tool for use in when such reports are provided. We are absolute that this enhanced process should not delay an early request for assistance where it is immediately apparent that such assistance is required but an SBAR should be provided once an initial assessment has occurred. We accept that on this occasion there should have been a more comprehensive exchange of information between the LAS clinicians on scene and the clinician in the control room. The clinical handover for Mr Ahmed did not meet our expected standard and for this, we are very sorry. We recognise the importance of ongoing refresher training to ensure staff are kept up to date and reminded of their training and the expected format and standard for such clinical handovers. To serve as a refresher to clinical staff and a checklist to refer to, a Medical Director’s bulletin has been jointly prepared by the LAS and LAA, attached for your reference. The Bulletin sets out the process for an SBAR clinical handover, the information to be included and practical advice on how to approach the handover to ensure best practice is consistently achieved. The bulletin also includes case study examples to demonstrate how the handover should work in practice. The bulletin will be circulated to all LAS clinical staff and LAA paramedics by email and will be available on the LAS intranet ‘The Pulse’ and accessible to staff through their personal issue IPads. The content of the bulletin will also be disseminated at sector level through management team communication. This bulletin will also be shared with clinical staff working within the operations centre including the LAA flight paramedics. The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed. Clinical handover already forms part of the pre-registrant paramedic-training course provided through our partner universities. To ensure students are educated in the importance of this process and to provide practical advice on how to best utilise this as part of clinical practice, we are sharing a copy of the bulletin with our partner universities and requesting that this teaching is reinforced during the appropriate modules on the course and using the SBAR format.
We hope this response is helpful in setting out the ongoing work that the LAS are LAA are engaged with to ensure our staff are fully trained and up to date in the importance of providing an SBAR clinical handover when requiring additional clinical support or when asked to provide a clinical report and that this is applied consistently as part of good clinical practice. The LAS and LAA will continue to work in close partnership and will ensure ongoing communication and collaboration to achieve the best clinical outcomes for our patients. Dr
Medical Director, London’s Air Ambulance
LAA resources to patients in greatest need. This is not an easy or straightforward task when there are many thousands of calls to review, with each call requiring prompt and appropriate clinical triage and assessment. Monitoring all potentially relevant 999 calls coming in presents a challenge and ultimately means that some degree of clinical judgement is required based on the information that is obtained from the caller as well as the clinicians on scene. Over the last 30 years, we have developed a staged model of dispatch this is based around three levels of dispatch: (1) Immediate; this is a small cohort of cases where evidence tells us that without further information LAA skills may be required on scene and if available LAA are immediately dispatched. This includes cases such as a person struck by a train or a patient falling more than 20ft. (2) Interrogation; this is where further information needs to be gained from the 999 caller before a decision to dispatch can be made. This can be a silent process where the LAA paramedic in the operations centre listens to the 999 call for additional information that may be provided by the caller, or this can be an active process where the clinician speaks directly with the 999 caller to gain further information to inform the dispatch decision once the initial 999 call is complete. (3) Crew/Clinician request; this is where the attending ambulance clinician who arrives on scene either is asked to provide a clinical update or they directly request the attendance of the team from LAA. These processes are embedded with the Standard Operating Procedures for LAA and through the major trauma networks there are processes in place to ensure that we monitor cases, which may have benefited from the attendance of the enhanced care team from LAA and one was not sent. These are fed back through the LAS to the lead flight paramedic for review. These are very rare. Over the last three years we have further enhanced the ability for interrogation of calls with the use of video triage. Video triage is utilised through the Good Sam software, which allows, with the appropriate permissions, the clinician to view the incident using the camera on the callers’ phone. This technology can also be used to further inform the clinical report provided by the ambulance clinicians on scene. The SBAR (Situation, Background, Assessment, Recommendation) acronym is an established tool within the LAS and is used nationally within healthcare to minimise the risk of key information being missed when a handover is provided. This format is also used by our staff when handing over patients at hospital or when passing information to other clinicians such as GPs to promote best practice in clinical decision making via discussion. As we move forward we have been explicit that the SBAR tool should be used when providing a clinical handover to either the LAA paramedic or Advanced Paramedic Practitioner (or any other clinician) in the operations centre, to ensure the decision on deployment of an advanced clinical resource can be properly considered.
The SBAR tool was developed by the National Patient Safety Agency. The SBAR handover is designed to provide a structure for passing clinical information which is reproducible and aims to minimise risk of either incomplete information being passed or this being misinterpreted due to the ‘human factors’ experienced in a high pressure clinical situation. To provide further assurance around the information which is passed from clinicians on scene to inform the dispatch of further specialist resources we will expand the use of the SBAR handover tool for use in when such reports are provided. We are absolute that this enhanced process should not delay an early request for assistance where it is immediately apparent that such assistance is required but an SBAR should be provided once an initial assessment has occurred. We accept that on this occasion there should have been a more comprehensive exchange of information between the LAS clinicians on scene and the clinician in the control room. The clinical handover for Mr Ahmed did not meet our expected standard and for this, we are very sorry. We recognise the importance of ongoing refresher training to ensure staff are kept up to date and reminded of their training and the expected format and standard for such clinical handovers. To serve as a refresher to clinical staff and a checklist to refer to, a Medical Director’s bulletin has been jointly prepared by the LAS and LAA, attached for your reference. The Bulletin sets out the process for an SBAR clinical handover, the information to be included and practical advice on how to approach the handover to ensure best practice is consistently achieved. The bulletin also includes case study examples to demonstrate how the handover should work in practice. The bulletin will be circulated to all LAS clinical staff and LAA paramedics by email and will be available on the LAS intranet ‘The Pulse’ and accessible to staff through their personal issue IPads. The content of the bulletin will also be disseminated at sector level through management team communication. This bulletin will also be shared with clinical staff working within the operations centre including the LAA flight paramedics. The content of the bulletin will be further reinforced by being incorporated into the LAS Core Skills Refresher training modules. Where appropriate and where scenario based education is occurring, staff will be expected to utilise the SBAR handover when passing clinical information. We have also updated the training for those clinicians who may receive such information, within the operations centre and how to prompt an SBAR handover if needed. Clinical handover already forms part of the pre-registrant paramedic-training course provided through our partner universities. To ensure students are educated in the importance of this process and to provide practical advice on how to best utilise this as part of clinical practice, we are sharing a copy of the bulletin with our partner universities and requesting that this teaching is reinforced during the appropriate modules on the course and using the SBAR format.
We hope this response is helpful in setting out the ongoing work that the LAS are LAA are engaged with to ensure our staff are fully trained and up to date in the importance of providing an SBAR clinical handover when requiring additional clinical support or when asked to provide a clinical report and that this is applied consistently as part of good clinical practice. The LAS and LAA will continue to work in close partnership and will ensure ongoing communication and collaboration to achieve the best clinical outcomes for our patients. Dr
Medical Director, London’s Air Ambulance