Vhari Ingall and Mary Johnson

Dear Mr Ridley Prevention for Future Death report touching on the deaths of Mrs Mary Johnson and Ms Vhari lngall. I write in connection with your inquiries touching on the deaths of Mrs Mary Johnson and Ms Vhari lngall, and in response to the Prevention for Future Deaths Report issued to South Western Ambulance Service Foundation Trust on 1s~ou will be aware that the report was marked for the attention of my predecessor-Mr~ please note that I have since assumed the role of Chief Executive Officer and accordingly have sought to address the concerns you raise below. I was extremely saddened to hear of both Mrs Johnson and Ms lngall's deaths and understand that the circumstances of these deaths would have been extremely difficult for both families. I would therefore like to take this opportunity to offer my sincere condolences to the families of both Mrs Johnson and Ms lngall and to reassure you that both cases have been taken extremely seriously, with a significant amount of work undertaken to ensure any learning identified is embedded within the organisation. Whilst I am aware that the events leading to their respective deaths were somewhat different, HM Coroner has, within the report drawn parallels between the two incidents, identifying two chief concerns:
• Do Not Resuscitate (DNAR) Forms only apply in circumstances where patients will have a 'natural' death and would therefore not be applicable in circumstances where a patient has self-harmed as this could in no way be considered a 'natural' death and
• The requirement for paramedics to make decisions regarding the resuscitation of patients who have self-harmed and who are in possession of documents that purport to support their actions. In order to address the concerns, I would advise that both patient deaths have been investigated separately by way of Review, Learn and Improve investigations (formerly known as Serious Incident investigations) and comprehensive reports compiled, both of which will be shared with the respective families and will be provided to HM Coroner separately. Although distinct from one another, the investigations have run concurrently and have sought to address a myriad of complex issues, ranging from:
• Capacity assessment in intoxicated patients, how this is assessed and the factors to be considered;

• Consent to treatment in circumstances where a patient has refused treatment and is assessed as having capacity;
• Best-interest decision making and the weight to be apportioned to each factor considered;
• The validity and applicability of documentation including DNARs and advanced decision documentation in circumstances where a patient has self-harmed;
• The extent to which paramedics should exercise professional curiosity;
• Availability and accessibility of available guidance for paramedic crews;
• The extent to which paramedics are able to access expert mental health and senior clinical support externally. One of the similarities between the two cases is that Mrs Johnson and Ms lngall both had DNAR forms in addition to other documentation including advance decisions or a TEP (Treatment Escalation Plan) and notes expressing a wish to end their lives. A DNAR form is not a legally binding document and as HM Coroner has identified, would not be applicable in circumstances where a patient has self-harmed, as this would not achieve a naturally occurring death. Conversely, an advanced decision (or ADRT (advanced decision to refuse treatment)) may be applicable if specific to the set of circumstances, is valid and there is no reason to doubt the patient's capacity at the time of writing. In the case of Mrs Johnson, the investigation revealed that the paramedic who attended her was aware that the DNAR documentation was not applicable but was nevertheless keen to ensure Mrs Johnson's wishes were factored into the decision making, as expressed by her actions in taking an apparent overdose and within the documentation provided, which included a note detailing her expressed wish to end her life. The paramedic sought advice from the Senior Clinical Advisor on-call (ambulance senior clinician) on this point and having consulted with Mrs Johnson's family at length, made a 'best interests' decision to leave Mrs Johnson with her family- that is a decision that incorporates all known variables with a view to making what was perceived to be the right and best decision for the patient. In Ms lngall's case, the investigation showed that the paramedic crew spent a vast amount of time with her on scene, endeavouring to persuade her to go to hospital to receive treatment following an overdose of medication. Similarly, Ms lngall had both a DNAR and a TEP in her possession, neither of which applied. By contrast, although it was acknowledged by the crew that Ms lngall was intoxicated, they did not consider the level of impairment to be so great that it impacted on her capacity to make decisions, however unwise they might have been. The crew recall repeatedly assessing Ms lngall's capacity throughout their time with her and report that she was able to converse with them freely and demonstrated a clear understanding of the consequences of her actions, explaining that she was aware that she would die without treatment. The crew report that Ms lngall had capacity up until she rapidly deteriorated and went into respiratory arrest and made considerable attempts to seek external support via mental health and out of hours' services. Ultimately, although the crew mistakenly considered the documentation to be applicable, their decision to allow Ms lngall to die was predominantly based on their repeated assessment of her having the capacity to make her own decisions and the demonstration of her understanding of the consequences. They therefore did not consider it appropriate or in the patient's best interests to treat and resuscitate. Given the complexity of both cases and the plethora of issues explored, the investigating team reviewed the guidance available to crews with a view to establishing both the accessibility and level of clarity provided for the management of patients who have self-harmed and refuse Chalrman: - ­
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treatment. They found that whilst there is a wealth of national and internal guidance available, in situations such as those described above, where paramedics are faced with a multitude of issues, the relevant guidance is often contained within multiple sources, necessitating a need to read various texts in conjunction with one another to enable them to formulate a plan. Therefore, in addition to a clear requirement to reinforce education around the legality and applicability of documentation such as DNARs and ADRTs, in circumstances where a timely response is imperative, proactive steps have been taken by SWASFT to ensure a greater understanding of these issues and to embed the learning taken from these incidents with a view to improving the quality of the service provided to our patients and their families. In terms of the action taken by SWASFT, it was recognised that immediate action was required to ensure staff understood their legal obligations and could distinguish between the varying documents they might encounter, including DNARs, Advance decisions and a Lasting Power of Attorney (LPAs). Accordingly, as an interim measure, a Clinical Notice was issued to all staff on 22nd May 2020, a copy of which is enclosed for your ease of reference. It was, however, acknowledged that a more robust review of guidance was required, with a view to developing a more focused guideline identifying the key steps to be considered by crews, in addition to some detailed explanatory text identifying the legislation that underpins it. There ensued a process of collating the relevant information from various sources and incorporating it all into one accessible and easy to comprehend document. A guideline entitled 'Mental Health and capacity considerations in patients who present as having self-harmed or attempted suicide' has now been developed by the team, incorporating references to JRCALC (Joint Royal Colleges Ambulance Liaison Committee), NICE and internal SWASFT guidance. Given the complexity of the task, specialist legal input was sought in addition to the clinical expertise of a mental health expert who has provided some valuable insight into the management of patients who have self-harmed. One area HM Coroner may wish to explore further relates to the applicability of ADRTs in circumstances where the patient has self-harmed and refuses treatment. It is understood that provided the ADRT is valid, clearly provides for the specific set of circumstances in which the patient presents, and there is no reason to suspect the patient did not have capacity at the time of writing, the ADRT would be legally binding. The concern here is in relation to the capacity of the patient at the time the document was drafted, given this may not have been formally assessed and so may be questionable if in a state of suicidal crisis for example. Although the guideline attempts to address this matter, it is arguable that the law may need to be clarified around this point. The Trust will implement the new guideline on 14th October and will notify staff of this together with a briefing of the subject matter via the Chief Executive's bulletin the same day. Members of the Quality and Clinical Care directorate will then work alongside the Learning and Development team to design training materials to be delivered to staff as part of the 2021 /22 staff training package. Given the complexity of the subject matter, it will be important that the content is carefully considered and planned so as to ensure effective delivery to the workforce. Completion of the training is mandatory with the obvious exceptions made for those on maternity and sick leave. In previous years the Trust has routinely achieved 90-95% of the workforce trained with a firm plan to ensure that 100% of the workforce has received their education by the end of quarter 1 the following year. A copy of the guideline has been enclosed for information and the Trust will also share the new guidance with the Association of Ambulance Chief Executives and CQC in due course. In terms of other actions taken, although the formulation of a new guideline was a key recommendation made for both RLI investigations, other actions included working closely with local mental health trusts and out of hours' services to strengthen communication links and the support provided to paramedic crews managing mental health patients. In addition, although it is clear from

the investigations undertaken that the crew members did their very best for both patients, individual learning was identified and I understand all those involved have thoroughly reflected on the incidents and engaged extremely well in the investigation process. The Trust has also recognised the need to recruit a substantive Senior Mental Health Practitioner to provide ongoing advice and support to staff and to develop services sensitive to the needs of people with mental health issues or a learning disability. This role will provide strategic leadership ensuring mental health remains a key priority for the organisation. They will work with stakeholders to develop pathways of care and services for patients as well develop guidance and training for staff. One key work stream will be to discuss with commissioners the potential recruitment of mental health practitioners within the ambulance clinical hubs to provide immediate advice to crews. In conclusion, I hope both the families of Mrs Johnson and Ms lngall, and HM Coroner will be assured by the decisive steps taken by the Trust to address the concerns raised and furthermore by the considerable amount of work undertaken to implement improvements to the service the Trust provides to our patients and their families.

Dear Mr. Ridley, Regulation 28 report to prevent future deaths following the cases of Mary Grace Johnson and Vhari Ingall Following the commencement of your investigation into the deaths of Mrs. Johnson and Ingall, the Care Quality Commission (the 'CQC') received a copy of the Regulation 28 report because you felt that the commission has the power to take action: The CQC monitor; inspect and regulate services to make sure meet fundamental standards of quality and safety. CQC sets out what good and outstanding care looks like and work to make sure services meet fundamental standards below which care must never fall Background South Western Ambulance Service Foundation Trust (SWASFT) is registered with the CQC to provide the regulated activities of: Diagnostic and Screening Procedures Surgical Procedures Transport Services, triage and medical advice provided remotely Treatment of Disease, Disorder or Injury The trust provides these services from a range of bases in the Southwest of England with its headquarters based in Exeter. The service provided by SWASFT covers a geographical area of one fifth of England's land mass_ The most recent inspection report for SWASFT was published in September 2018, where the organisation was rated "Good" overall: The CQC became aware of the deaths of Mrs. Johnson and Ms. Ingall on 22 April 2020 upon receipt of the first regulation 28 report: At this time, SWASFT were contacted by the CQC to ask for the investigation reports into the deaths of the two patients. SWASFT began this investigation upon the receipt of the Regulation 28 report; and so at this time were able to send only the 72-hour investigation reports. Subsequent to the receipt of the amended Regulation 28 report; where the CQC were named as responders, further information was requested from SWASFT to enable a closer analysis both of the patients identified, but also Ms_ they

the processes and guidelines that supported front line staff in the treatment of all patients in similar circumstances_ Matters_of Concern: '1) Erontline workers are_taking decisions regarding non-resuscitation of individuals with a Do_Not Resuscitate (DNRLorder_in place_where it seems apparent that the individual has orhas attempted to take_his or her_own life ADNR document applies_to allow specifically a natural death Immediate Concerns Upon receipt of the regulation 28 report from the coroner and subsequent review processes, SWASFT were asked to provide assurance that actions had been taken to mitigate the immediate risk of a similar occurrence. The CQC were provided with this in the required timescale, along with information about how the receipt and understanding of this information was governed: This provided the CQC with a level of assurance that with immediate affect; the risk of a similar occurrence is mitigated as far as is practicable_ Ongoing Management of risk In addition to information about the management of immediate risk, the CQC asked SWASFT to review all cases of apparent suicide attended by their crews in the preceding 18 months where resuscitation had not been attempted. This review was conducted using a comprehensive review of systems used to capture information about patients and the treatment received. This demonstrated that in such cases, the decision not to resuscitate was legitimate in that these patients were past the point that resuscitation could have saved their livves and were in accordance with the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC): The CQC asked SWASFT for information that demonstrated an ongoing management plan of the situation so that it could be assured of the sustainability of such mitigations as described above. Information included within a letter sent to us on 10th June 2020 provided assurance of a comprehensive plan surrounding the development of a clearer process and policy for staff to follow, and training to sit alongside this subject SWASFT stated that the plan would be for this to have been completed by all staff by March 2021. It is fair to say that we have confidence in their ability to deliver the action plan as described, based on our knowledge and experience of the organisation: In putting together this plan, it is our understanding that SWASFT have worked with legal support to ensure that the information included in the new policy is not only clear and easier to access but is also legally accurate. With regards to the plans as outlined above, review of the achievement of this will form part of the CQC's ongoing engagement with SWASFT as well as being followed up directly with front-line staff and leaders at the next inspection. SWASFT were scheduled to have an inspection during the spring of 2020. However; due to the coronavirus pandemic, all routine inspections were cancelled. At the time of writing, it is not yet known when these will resume but it is not envisaged to be imminent: That being said, should a risk present that requires a closer examination through the use of an inspection, then one will be carried out. SWASFT's cooperation and readiness to mobilise a solution to the concerns outlined in the regulation 28 report does not

suggest a need to inspect at this time. However, should further information alter that viewpoint when the investigations are completed, the situation and decision to inspect will be reassessed: (2) The_belief of the coroner_that this may be a wider_issue_nationally and not limited to the_South Western Ambulance_Service Foundation Trust SWASFT Information surrounding the cases of these two patients, and the subsequent actions taken and information gained by CQC, has been shared with the national ambulance group that sits within the CQC. This means that the findings surrounding the deaths of these patients can be used to enhance engagement with, and ongoing inspections of, ambulance trusts across the country: As part of our inspection methodology, we routinely look at the training in, and presence and understanding of processes and policies surrounding the mental capacity act and best interest decisions_ This is ordinarily a more generic look at such subjects, and so the addition of this focus on patients who have apparently attempted to take their own lives will be promoted within the CQC by the ambulance group: Having reviewed the inspection reports of a number of ambulance trusts across the country, there is no evidence that as part of those inspections the CQC has specifically asked about the affect of apparent suicide in the presence of an DNR document: Through the channels of communication open to the ambulance group this question can be promoted to colleagues carrying inspections of these trusts in the future. Hopefully, this letter provides you with sufficient information about the concerns raised in the regulation 28 report surrounding the deaths of Mrs. Johnson and Ms. Ingall, together with our ongoing regulatory approach to the matter: Should you require any further information, please contact 'Inspection Manager) by phone on 03000| or via e mail at @cgc org.uk