East of England Ambulance Service
NHS / Health Body
Action Taken
The Trust has revised its EOC Standard Operating Procedure for Mental Health calls, giving guidance to consider Category 2 response if a call is abandoned and information suggests the patient is actively at risk. An ESOP is also in development to address abandoned calls and will include checks by the control room manager. (AI summary)
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Dear Ms Beasley-Murray Thank you for your communication regarding the Regulation 28 (Report to Prevent Future Deaths) in respect of the death of Sarah Ferneyhough: would like to offer my condolences to Sarah's family and those affected by this tragic event: can confirm we have distributed the report to the four organisations named in the report as per your request: AACE have confirmed they have reviewed the Trusts response and we are awaiting feedback from the other groups. have responded to the points raised in the Regulation 28 report separately below:
1. The deceased's call was described as an "abandoned call" and thereafter automatically categorised as a Category 3. A review of this practice is required; The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document: Within this ESOP , guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions) , and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call: There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust's governance and approval process_ This will be completed and released in December 2020_ Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include: Chest Pain Breathing Difficulty Loss of consciousness Severe haemorrhage (bleeding) Stroke PregnancylLabour Overdose Chief Executive: Chair: WWW eastamb.nhs.uk #WeAreEEAST
Calls with a mental health element such as suicidal intent, thoughts or threats, serious self- harm or mental health crisis 2 A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than Category 3 The Trust is awaiting a response on national coding but in the meantime has introduced the measures as described above to enable higher risk calls to be escalated and coded as a Category 2 where appropriate
3. In the situation leading up to Ms Ferneyhough's death; the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the "abandoned" call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the "abandoned" call or provided with full details of any medical information given. The ESOP on Abandoned Calls, in development; will now also include a series of checks that must be undertaken by the control room Manager. This includes requirement to listen to the call recording to ensure details given are accurate and the response is appropriate. This will also facilitate clinical escalation and review where required. hope this letter demonstrates the steps the Trust is taking in relation to our management of abandoned calls and calls where there are concerns about a patient's mental health. Please do not hesitate to contact me should you require a further update.
1. The deceased's call was described as an "abandoned call" and thereafter automatically categorised as a Category 3. A review of this practice is required; The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document: Within this ESOP , guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions) , and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call: There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust's governance and approval process_ This will be completed and released in December 2020_ Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include: Chest Pain Breathing Difficulty Loss of consciousness Severe haemorrhage (bleeding) Stroke PregnancylLabour Overdose Chief Executive: Chair: WWW eastamb.nhs.uk #WeAreEEAST
Calls with a mental health element such as suicidal intent, thoughts or threats, serious self- harm or mental health crisis 2 A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than Category 3 The Trust is awaiting a response on national coding but in the meantime has introduced the measures as described above to enable higher risk calls to be escalated and coded as a Category 2 where appropriate
3. In the situation leading up to Ms Ferneyhough's death; the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the "abandoned" call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the "abandoned" call or provided with full details of any medical information given. The ESOP on Abandoned Calls, in development; will now also include a series of checks that must be undertaken by the control room Manager. This includes requirement to listen to the call recording to ensure details given are accurate and the response is appropriate. This will also facilitate clinical escalation and review where required. hope this letter demonstrates the steps the Trust is taking in relation to our management of abandoned calls and calls where there are concerns about a patient's mental health. Please do not hesitate to contact me should you require a further update.