London Ambulance Service
NHS / Health Body
Action Taken
The LAS has implemented leadership training and Acute Behavioural Disturbance (ABD) refresher training. They collaborated on national guidance for ABD for ambulance staff and are sharing updated clinical guidelines via tablet devices. Learning from the death has been presented to the JRCALC guidelines group. (AI summary)
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Dear Sir , Regulation 28; Prevention of Future_Deaths Report (PFD} arising the inquest into the death of Kevin CLARKE Thank you for your Regulation 28 Report dated 18th February 2021 setting out your concerns to be addressed, would like to begin by expressing my deepest condolences to the family of Mr Clarke and to reaffirm the sincere apology that was expressed on behalf of the London Ambulance Service NHS Trust (the LAS) at the inquest for the failures in our care for Mr Clarke, for these am truly sorry. Prior to the inquest a detailed review was undertaken to investigate the circumstances surrounding the LAS attendance to Mr Clarke on 9th March 2018. It was recognised and accepted by the Trust in evidence heard at the inquest that the care provided to Mr Clarke by the attending ambulance clinicians fell significantly below our expected standard: The Trust fully accepts the findings and conclusion of the Jury in setting out the failures which were determined to have contributed to Mr Clarke'$ tragic death The concerns set out in the PFD report; as directed to the LAS were in respect of the clear lack of leadership, risk assessment or challenge on health and safety of Mr Clarke by the paramedic, for whom it appeared to you to have insufficient seniority. In addition, vour concerns detail inadequate communication with police on scene about the critical conveyance decision as well as inadequacy of supervision and the 'collective leadership' approach where decision making seemed to emerge without discussion: will set out the LAS response to these as follows: Leadership training and Acute Behavioural Disturbance (ABDLrefresher_training The Royal College of Emergency Medicine sets out that Acute Behavioural Disturbance (ABD) is the accepted terminology adopted by the UK Police Forces, the Ambulance Services and the Faculty of Forensic and Legal Medicine. It describes the sudden onset of aggressive and violent behaviour and autonomic dysfunction, typically in the setting ofacute on chronic abuse or serious mental illness.
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The LAS fully recognises the need to ensure that all our front line staff are trained to recognise and manage appropriately patients who are displaying signs of ABD and that whilst when attending Mr Clarke, our first on scene ambulance clinicians were appropriately clinically trained to manage such medical emergency, it is accepted that there was clearly a lack of provision of adequate clinical leadership. The Trust fully appreciates that clinical skills alone are not enough when faced with these circumstances and additional clinical leadership training that supports the clinical skill set is equally essential: Our expectation is that front line clinicians need to immediately recognise and manage their role on scene as having clinical primacy for the patient and be confident in managing multi-disciplinary scene, always advocating for their patient utilising the skills of others on scene to ensure their safety whilst putting the clinical need to the patient at the forefront_ ability to communicate effectively with our emergency service colleagues to ensure the best interests of the patient are being constantly reviewed and risk assessed. We provided evidence at the inquest to explain how our front line staff are trained and kept up to date via our Core Skills Refresher (CSR) training, which is a mandatory annual programme providing front line staff with three, eight hour training sessions per year: Since 2010 our crews have been trained in ABD and in recognition of how important ABD training is for ambulance clinicians, we have introduced ABD training a5 part of the syllabus for all clinicians joining the LAS and this will be incorporated for every new entrant who joins April 2021_ As we set out in evidence, we are committed to regularly increasing the knowledge and awareness of our front line staff on ABD and it will be included in our next CSR training which is due to be delivered in 2021/2022, subject to Covid-19 restrictions. The ABD (CSR) training will cover the spectrum across which patient with ABD can present and will be focussed towards scenarios and practical application of the assessment and management of ABD, including communicating with other agencies on scene_ Our intention is to make sure regular refreshers are not only available through mandatory training but that we engage staff in additional methods to the subject at the forefront of clinical updates and as such we have created an ABD podcast which will be available to all staff with the next clinical update bulletin: This will be complete before the end of the August 2021. A clinical update article on ABD is currently finalised and will be disseminated to all front line staff via our intranet 'The Pulse as well as received by email sent directly to staff:. Communicating with our emergency service colleagues The vital need to advocate for the safe and effective management of the patient is core to this and the Trust expects that all our ambulance clinicians are trained for and confident in knowing the importance of their role on scene The CSR training will include communication strategies to further empower ambulance clinicians to communicate with the police in such situations: Resourcing the scene and providing senior leadership Recognising the challenge which you have highlighted around the "insufficient seniority or experience" of the ambulance clinicians who attended Mr Clarke, there has been a program of national change in respect of paramedics transition into fully independent clinical practice, when initially qualify. This program has
and The from keep being how they
introduced the formal role of Newly Qualified Paramedic (NQP) where there is a two-vear preceptorship program, where the graduate paramedic has a formal period of direct supervision on qualification, this then transitions through to period of further supported development during their first two vears in clinical practice: This process has formal 'gateways' which the paramedic must meet in order progress and the entire process is supported by development portfolio. This development program is linked to the paramedic' $ remuneration and in order to achieve the uplift in salary, this program must be completed. This program now aims to provide a structured development program for paramedics entering the profession and improve the experience and seniority of the national paramedic workforce. The LAS recognises the importance of getting resources to scene to treat patients with ABD in the fastest possible time and recognises that the complexity of the scene can call for enhanced clinical leadership presence to support the care of the patient and the management of the scene_ This can be especially important in dynamic scene such as in the circumstances of Mr Clarke, where multi agency working is necessary: We provided evidence at the inquest to detail our commitment to continue to monitor and review the use of 'Category 1' triage for potential ABD patients, which goes above the national position and demonstrates the importance the LAS place on ensuring the timeliest of response to this cohort of patients. The LAS will continue to work with the police to ensure this is used correctly to maximise benefit and will continue to highlight the need for accurate and concise sharing of information where ABD is suspected: The LAS will continue to ensure that the process for this upgrade of calls is shared within our Emergency Operations Centres You also heard evidence that where pharmacological tranquilisation of an ABD patient is indicated, our Advanced Paramedic Practitioners (critical care) are trained to undertake pharmacological tranquilisation where possible we will continue to provide this treatment option when it is indicated_ We are one of the few UK ambulance services where this intervention is delivered by the ambulance services' own paramedic workforce, and we actively target this cohort of staff to this group of patients In order to further enhance the clinical leadership experience on scene we are working through a process of change in order to pro-actively send either a Clinical Team Manager (or an Incident Response Manager) to calls where the Metropolitan Police Service or other Police service, report a case of suspected ABD. This must not distract from the timely response of the nearest available clinical resource, but will provide additional leadership on scene to support our frontline clinicians and enhance patient care. In order to optimise this response, ABD training will be to be included in the package of education for our Clinical Team Managers (CTM) to further develop their core knowledge. There are two, two hour online learning sessions taking place before the end of April 2021. Staff attendance will be recorded and each CTM will have to report to confirm that they have completed the sessions. Nationalclinicalguidance updates The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and the National Ambulance Services Medical Directors Group (NASMED) have published an ABD clinical guideline, specifically for ambulance staff, within the Clinical Practice Guidelines: This is the first national guidance on ABD for ambulance staff in the UK. The LAS have worked in partnership with national team in developing this guideline welcomes this significant improvement in patient care:
rapid and and
The LAS established processes for sharing updated clinical guidelines digitally with our clinicians through the use of personally issued tablet devices to staff which alert staff to updated clinical guidelines. Further to this my Chief Medical Officer, who chairs the National Medical Directors Group is keen to ensure the update of these guidelines to reflect learning_ our Clinical Practice Development Manager for Critical Care, who you heard at the inquest, has joined the group which is developing and reviewing these guidelines and the learning from Mr Clarke'$ death has been presented to the chair of the JRCALC guidelines group: very much hope this response helps in setting out the ongoing work that the LAS are engaged with to ensure staff are fully up date and trained in the importance of ABD as the priority and the ongoing work to further develop and monitor Trust wide learning and communicate this to our staff: ABD training and will remain at the forefront of our agenda and our expectations of our staff in demonstrating not only high standard of clinical treatment but also leadership and the absolute requirement to advocate for their patient; always putting their best interests at the forefront of clinical decision making: LAS will continue to further this work with our staff to ensure they are well trained and on a national basis in respect of the development of clinical learning in an ongoing commitment to learn from Mr Clarke'$ tragic death, with the overarching aim to do all we can to mitigate the risks ofanother death in these circumstances_ sincerely Chief Executive, London Ambulance Service NHS Trust
has regular from The Yours
from drug
The LAS fully recognises the need to ensure that all our front line staff are trained to recognise and manage appropriately patients who are displaying signs of ABD and that whilst when attending Mr Clarke, our first on scene ambulance clinicians were appropriately clinically trained to manage such medical emergency, it is accepted that there was clearly a lack of provision of adequate clinical leadership. The Trust fully appreciates that clinical skills alone are not enough when faced with these circumstances and additional clinical leadership training that supports the clinical skill set is equally essential: Our expectation is that front line clinicians need to immediately recognise and manage their role on scene as having clinical primacy for the patient and be confident in managing multi-disciplinary scene, always advocating for their patient utilising the skills of others on scene to ensure their safety whilst putting the clinical need to the patient at the forefront_ ability to communicate effectively with our emergency service colleagues to ensure the best interests of the patient are being constantly reviewed and risk assessed. We provided evidence at the inquest to explain how our front line staff are trained and kept up to date via our Core Skills Refresher (CSR) training, which is a mandatory annual programme providing front line staff with three, eight hour training sessions per year: Since 2010 our crews have been trained in ABD and in recognition of how important ABD training is for ambulance clinicians, we have introduced ABD training a5 part of the syllabus for all clinicians joining the LAS and this will be incorporated for every new entrant who joins April 2021_ As we set out in evidence, we are committed to regularly increasing the knowledge and awareness of our front line staff on ABD and it will be included in our next CSR training which is due to be delivered in 2021/2022, subject to Covid-19 restrictions. The ABD (CSR) training will cover the spectrum across which patient with ABD can present and will be focussed towards scenarios and practical application of the assessment and management of ABD, including communicating with other agencies on scene_ Our intention is to make sure regular refreshers are not only available through mandatory training but that we engage staff in additional methods to the subject at the forefront of clinical updates and as such we have created an ABD podcast which will be available to all staff with the next clinical update bulletin: This will be complete before the end of the August 2021. A clinical update article on ABD is currently finalised and will be disseminated to all front line staff via our intranet 'The Pulse as well as received by email sent directly to staff:. Communicating with our emergency service colleagues The vital need to advocate for the safe and effective management of the patient is core to this and the Trust expects that all our ambulance clinicians are trained for and confident in knowing the importance of their role on scene The CSR training will include communication strategies to further empower ambulance clinicians to communicate with the police in such situations: Resourcing the scene and providing senior leadership Recognising the challenge which you have highlighted around the "insufficient seniority or experience" of the ambulance clinicians who attended Mr Clarke, there has been a program of national change in respect of paramedics transition into fully independent clinical practice, when initially qualify. This program has
and The from keep being how they
introduced the formal role of Newly Qualified Paramedic (NQP) where there is a two-vear preceptorship program, where the graduate paramedic has a formal period of direct supervision on qualification, this then transitions through to period of further supported development during their first two vears in clinical practice: This process has formal 'gateways' which the paramedic must meet in order progress and the entire process is supported by development portfolio. This development program is linked to the paramedic' $ remuneration and in order to achieve the uplift in salary, this program must be completed. This program now aims to provide a structured development program for paramedics entering the profession and improve the experience and seniority of the national paramedic workforce. The LAS recognises the importance of getting resources to scene to treat patients with ABD in the fastest possible time and recognises that the complexity of the scene can call for enhanced clinical leadership presence to support the care of the patient and the management of the scene_ This can be especially important in dynamic scene such as in the circumstances of Mr Clarke, where multi agency working is necessary: We provided evidence at the inquest to detail our commitment to continue to monitor and review the use of 'Category 1' triage for potential ABD patients, which goes above the national position and demonstrates the importance the LAS place on ensuring the timeliest of response to this cohort of patients. The LAS will continue to work with the police to ensure this is used correctly to maximise benefit and will continue to highlight the need for accurate and concise sharing of information where ABD is suspected: The LAS will continue to ensure that the process for this upgrade of calls is shared within our Emergency Operations Centres You also heard evidence that where pharmacological tranquilisation of an ABD patient is indicated, our Advanced Paramedic Practitioners (critical care) are trained to undertake pharmacological tranquilisation where possible we will continue to provide this treatment option when it is indicated_ We are one of the few UK ambulance services where this intervention is delivered by the ambulance services' own paramedic workforce, and we actively target this cohort of staff to this group of patients In order to further enhance the clinical leadership experience on scene we are working through a process of change in order to pro-actively send either a Clinical Team Manager (or an Incident Response Manager) to calls where the Metropolitan Police Service or other Police service, report a case of suspected ABD. This must not distract from the timely response of the nearest available clinical resource, but will provide additional leadership on scene to support our frontline clinicians and enhance patient care. In order to optimise this response, ABD training will be to be included in the package of education for our Clinical Team Managers (CTM) to further develop their core knowledge. There are two, two hour online learning sessions taking place before the end of April 2021. Staff attendance will be recorded and each CTM will have to report to confirm that they have completed the sessions. Nationalclinicalguidance updates The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and the National Ambulance Services Medical Directors Group (NASMED) have published an ABD clinical guideline, specifically for ambulance staff, within the Clinical Practice Guidelines: This is the first national guidance on ABD for ambulance staff in the UK. The LAS have worked in partnership with national team in developing this guideline welcomes this significant improvement in patient care:
rapid and and
The LAS established processes for sharing updated clinical guidelines digitally with our clinicians through the use of personally issued tablet devices to staff which alert staff to updated clinical guidelines. Further to this my Chief Medical Officer, who chairs the National Medical Directors Group is keen to ensure the update of these guidelines to reflect learning_ our Clinical Practice Development Manager for Critical Care, who you heard at the inquest, has joined the group which is developing and reviewing these guidelines and the learning from Mr Clarke'$ death has been presented to the chair of the JRCALC guidelines group: very much hope this response helps in setting out the ongoing work that the LAS are engaged with to ensure staff are fully up date and trained in the importance of ABD as the priority and the ongoing work to further develop and monitor Trust wide learning and communicate this to our staff: ABD training and will remain at the forefront of our agenda and our expectations of our staff in demonstrating not only high standard of clinical treatment but also leadership and the absolute requirement to advocate for their patient; always putting their best interests at the forefront of clinical decision making: LAS will continue to further this work with our staff to ensure they are well trained and on a national basis in respect of the development of clinical learning in an ongoing commitment to learn from Mr Clarke'$ tragic death, with the overarching aim to do all we can to mitigate the risks ofanother death in these circumstances_ sincerely Chief Executive, London Ambulance Service NHS Trust
has regular from The Yours